Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures: 17,341 patients from the Norwegian Hip Fracture Register

Aims The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN.acceptedVersio

Surgical Treatment of Distal Radial Fractures with External Fixation Versus Volar Locking Plate A Multicenter Randomized Controlled Trial

Background: The use of volar locking plate fixation (VLP) for unstable extra-articular distal radial fractures has increased in the last decades. External fixation (EF) is less frequently used. This change of surgical approach has only to some extent been evidence-based. Methods: In this multicenter, randomized controlled trial, we compared VLP and EF in patients between 18 and 70 years of age who had a displaced extra-articular distal radial fracture (OTA/AO type A3). The patients were examined at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome measure was the Patient-Rated Wrist/Hand Evaluation score (PRWHE). Secondary outcomes were the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), pain score on a visual analog scale (VAS), and radiographic measurements. Range of motion, grip strength, finger stiffness, complications, and reoperations were also recorded. Results: One hundred and fifty-six patients were included. One hundred and forty-two (91%)—127 women (89%) and 15 men (11%)—completed 1 year of follow-up. Sixty-nine patients were treated with VLP and 73, with EF. The mean age was 56 years. At 6 weeks, the median PRWHE score was significantly higher in the EF group (44) compared with the VLP group (27) (p < 0.001). At 3 months and 1 year, the difference between groups was not significant. The median QuickDASH score was 27 in the VLP group and 43 in the EF group at 6 weeks (p < 0.001), and a significant difference persisted at 3 months (p = 0.023). The VLP group had superior results in terms pain during activity, wrist extension, and ulnar and radial deviation at 1 year, whereas the number of major complications was similar in the 2 groups. Conclusions: Patients treated with VLP had earlier recovery of function compared with patients treated with EF. One year postoperatively, we found no significant functional difference.publishedVersio

Introducing teachers to new semiotic tools for writing instruction and writing assessment : consequences for students’ writing proficiency

Author´s accepted manuscript (postprint).This is an Accepted Manuscript of an article published by Taylor & Francis in Assessment in Education: Principles, Policy & Practice on 28/05/2017, available online: http://www.tandfonline.com/10.1080/0969594X.2017.1330251.acceptedVersio

Exploratory analyses on the effect of time since last meal on concentrations of amino acids, lipids, one-carbon metabolites, and vitamins in the Hordaland Health Study

Purpose Dietary intake may have pronounced effects on circulating biomarker concentrations. Therefore, the aim was to provide a descriptive overview of serum metabolite concentrations in relation to time since last meal, focusing on amino acids, lipids, one-carbon metabolites, and biomarkers of vitamin status. Methods We used baseline data from the observational community-based Hordaland Health Study, including 2960 participants aged 46–49 years and 2874 participants aged 70–74 years. A single blood draw was taken from each participant, and time since last meal varied. Estimated marginal geometric mean metabolite concentrations were plotted as a function of time since last meal, up to 7 h, adjusted for age, sex, and BMI. Results We observed a common pattern for nearly all amino acids and one-carbon metabolites with highest concentrations during the first 3 h after dietary intake. Homocysteine and cysteine were lowest the 1st hour after a meal, while no patterns were observed for glutamate and glutamic acid. The concentrations of phylloquinone and triglycerides were highest 1 h after dietary intake. Thiamine and thiamine monophosphate concentrations were highest, while flavin mononucleotide concentrations were lowest within the first 2 h after a meal. No clear patterns emerged for the other fat-soluble vitamins, blood lipids, or B-vitamin biomarkers. Conclusion Our findings suggest that distinguishing between “fasting” and “non-fasting” blood samples may be inadequate, and a more granular approach is warranted. This may have implications for how to account for dietary intake when blood sampling in both clinical and research settings.publishedVersio

Treatment of trochanteric and subtrochanteric hip fractures: Sliding hip screw or intramedullary nail?

Background: Trochanteric and subtrochanteric fractures are usually treated with a sliding hip screw (SHS) or an intramedullary (IM) nail, and the question whether a SHS or an IM nail should be the preferred implant for all or subgroups of fractures has not come to a final conclusion. In recent years, there has been a trend towards more use of IM nails, but this trend has not been driven by better results in well designed clinical trials. Regardless of type of implant, complications have to be encountered and to which extent modern implants have improved results remains unclear. Aims: It was our first aim to assess whether treatment with the new TRIGEN INTERTAN intramedullary nail resulted in less postoperative pain, better function, and improved quality of life for patients with trochanteric and subtrochanteric fractures compared to treatment with the SHS (Papers I and IV). Surgical complications and reoperation rates were also assessed. Secondly, we wanted to compare postoperative pain, function, quality of life, and reoperation rates for patients operated with IM nails and SHS for different subgroups of trochanteric and subtrochanteric fractures at a national level (Papers II and III). Patients and methods: 684 elderly patients with trochanteric and subtrochanteric fractures were included and treated with a SHS or the Intertan nail in a multicenter randomized controlled trial (RCT) (Paper I). The patients were assessed during hospital stay and at 3 and 12 months postoperatively. The 159 patients with reverse oblique trochanteric (AO/OTA type A3) and subtrochanteric fractures were separately analyzed and discussed in depth (Paper IV). Using data from the Norwegian Hip Fracture Register in papers II and III, we analyzed 7643 operations for simple two-part trochanteric fractures (AO/OTA type A1) (Paper II) and 2716 operations for reverse oblique and subtrochanteric fractures (Paper III) after treatment with either a SHS or an IM nail. Results: As presented in Papers I and IV patients operated with the Intertan nail had slightly less pain at early postoperative mobilization compared to those operated with a SHS, but we found no difference at 12 months. Regardless of fracture type, mobility, hip function, quality of life, and surgical complication rates were comparable for the two groups at 12 months. In simple two-part trochanteric fractures (Paper II) the SHSs had a lower complication rate compared to IM nails one year postoperatively (2.4% and 4.2% for SHS and IM nail, respectively, p = 0.001). Only minor, and clinically insignificant differences between the groups were found for pain, patient satisfaction, and quality of life. In Paper III, conversely, we found that the patients operated with an IM nail had a significantly lower failure rate compared to the SHS one year postoperatively (3.8% vs. 6.4%, respectively, p = 0.011). Small differences regarding pain, patient satisfaction, quality of life, and mobility were also in favor of IM nailing. Conclusions: Pain, function, quality of life, and reoperation rates were similar for the Intertan nail and the SHS in trochanteric and subtrochanteric fractures 12 months postoperatively. Data from our hip fracture register, however, favored the SHS in simple two- part trochanteric fractures, whereas IM nails had the lower complication rate and better clinical results in reverse oblique and subtrochanteric fractures. Accordingly, a differentiated treatment algorithm based on fracture type could be considered

Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures

Background Sliding hip screws (SHSs) and intramedullary (IM) nails are well-documented implants for simple two-part intertrochanteric fractures; however, there is no consensus regarding which type of implant is better. Questions/purposes We asked whether patients with simple two-part intertrochanteric fractures treated with IM nailing had (1) a lower reoperation rate and (2) less pain and better quality of life than patients treated with SHSs

Standards as a tool for teaching and assessing cross-curricular writing

In this article, we present the specific criteria that are currently being introduced in Norwegian teaching and assessment of writing, as well as selected aspects of their development. The article builds on an assumption that assessment criteria have such educational importance that even their origins, intellectual trajectories and underpinnings should be given attention in educational research. In this context, the article presents elements of a rare approach, in that national ‘norms of expected proficiency’ at politically predefined educational grade levels have been grounded in sustained collaboration with experienced teachers of writing across the curriculum, and may thus be viewed as yet unofficial ‘standards’. In the first step, a combination of existing curricula and literature review of writer development was used to tentatively draft a first set of criteria for the grades included in a 2005 national test of writing (grades 4, 7, 10 and 11). In the second step, such criteria were developed through an iterative, long-term process where initial criteria were confronted with the judgements of experienced teachers. Through ‘think aloud’ assessment interviews, pairs of teachers across Norway were asked to assess specific cases of students’ writings and voice criteria for their judgements, both within and across a series of domains. In the third step, interview transcripts were used to search for criteria used by several pairs of locally situated teachers across geographically distributed schools. Criteria thus identified were pooled into a refined set of ‘national standards’ that were subsequently tested out in everyday classroom contexts. On the basis of this confrontation with educational reality, the set has been further refined to form the version presented in this article. The Norwegian case raises a range of issues related to curriculum development, ‘standards’ and educational sustainability

TRIGEN INTERTAN Intramedullary Nail Versus Sliding Hip Screw

Background: Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture. Methods: In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed. Results: Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67). Conclusions: INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures