Complications in trochanteric and subtrochanteric femoral fractures

The hip fracture is a major public health problem. The majority of hip fracture patients are elderly with comorbidities and there is a strong association with osteoporosis, especially for the extracapsular (trochanteric and subtrochanteric) types of fractures. The management of these patients is associated with a huge risk for medical and surgical complications. One of the most important risks is significant blood-loss and a subsequent need for blood transfusion. The treatment of choice for patients with extracapsular hip fracture is acute surgery with internal fixation, such as intramedullary nailing or plating with sliding hip screw. A hip arthroplasty is a salvage procedure and an option for the treatment of failures after internal fixation. In this doctoral project we study the complications, the epidemiology and the influence of early surgery in the management of this subgroup of hip fracture patients. In Study I, a retrospective cohort study with a 5–11 years follow-up, 88 patients reoperated 1999 – 2006 at SÖS with a secondary hip arthroplasty due to healing complications after internal fixation of a trochanteric or a subtrochanteric fracture were analysed. The total reoperation rate was 16% (14/88). The most common reason for a reoperation was a periprosthetic fracture (n = 6). Multivariable Cox regression analysis of reoperations using femoral stems with standard length, compared with long stems, showed a trend for increased risk with a hazard ratio (HR) of 4 (p = 0.06). A recommendation for using long femoral stems may be one way to reduce the risk for reoperations. In Study II, a retrospective cohort study, 987 patients operated with an intramedullary nail due to an unstable trochanteric or subtrochanteric hip fracture at SÖS, between January 1, 2011 and December 31, 2013 were analysed. Using the red blood cell transfusion rate and mortality as the main outcome measures, logistic regression analysis was used to adjust for anticoagulants, ASA class, fracture type, preoperative haemoglobin (Hb) value and time to surgery. It was found that anticoagulants (relative risk (RR) 2.0) and surgery delayed for more than 24 hours (RR 3.9) were significantly associated with an increased rate of preoperative transfusions. In Study III, a retrospective case-control study of 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant were analysed. All patients were operated at SÖS within 24 hours with an intramedullary nail due to a trochanteric or subtrochanteric hip fracture after a low-energy trauma between January 1, 2011 and December 31, 2014. 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). There were no significant differences in the calculated blood-loss, in-house adverse events, mortality or pre- or perioperative transfusion rates between the groups. There was an increased rate of postoperative transfusions in the control group. The study demonstrated the safety of using vitamin K and/or PCC to be able to operate within 24 hours. In Study IV, a descriptive epidemiological register study, a total of 10548 patients registered in the national Swedish Fracture Register from January 2014 to December 2016 were analysed. 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 from the Swedish Death Register. The majority of the patients were elderly females (69%) who had sustained their fracture from a fall at the same level (83%) at the patients’ residence (75%). The most commonly used implant was a short antegrade intramedullary nail (42%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. Most of the patients were operated within 36 hours (90%). There was an increased mortality for males, and for all those who were delayed to surgery >36 hours. The major conclusions of this thesis were the epidemiological aspects, analyses showing the medical and surgical complexity of these fractures and the importance of optimising patients promptly before the surgery within 24 hours

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

Incidence of alcoholism in the revisited Lundby population, 1947-1997.

OBJECTIVE: The Lundby Study is a prospective longitudinal study of an unselected population consisting of 3,563 subjects. The Lundby Study started in 1947, and follow-ups were carried out in 1957, 1972, and in 1997. METHOD: In all four surveys, semistructured interviews were performed by psychiatrists. Registers, key informants, and case notes from hospitals and outpatient clinics supplemented the interview data. Best-estimate consensus diagnoses of mental disorders were applied after gathering all available data. In the present study, age- and sex-specific incidences of any alcoholism (alcohol problems and alcohol dependence) were studied for the entire 50-year period. Alcohol dependence was studied for the periods 1947-1972 and 1972-1997. Incidences and cumulative probabilities by age were calculated and compared. Age-standardized incidence rates were also calculated for five 10-year periods for subjects 40 years of age and older. RESULTS: Incidence rates of alcohol-use disorders show large differences across the life span. The cumulative probability for any alcoholism over the 50-year period was 24.4% for men and 4.0% for women. The incidence of any alcoholism was similar for men in both periods, whereas for women it increased in the period 1972-1997; however, this increase was not significantly on the 5% level. CONCLUSIONS: At least one in four men was found to be at risk of developing alcohol problems or becoming dependent on alcohol during his lifetime in the present study, which is in accordance with other studies. The gender differences in alcohol-use disorders in Sweden may have decreased in later decades

Remission from Alcohol Use Disorder among males in the Lundby Cohort during 1947-1997

Background. Alcohol use disorders are a major health problem, often with a chronic course. Studies on remission from alcohol use disorders are sparse. Objective. The aim of this study was to analyse the rate of remission from AUD and the possible influence of other mental disorders and sociodemographic factors on the remission in the Lundby Cohort. Method. Remission from AUD was studied for 312 male subjects in the Lundby Cohort, which was followed for 50 years. Cox regression analyses were used to study the possible influence of sociodemographic variables and other mental disorders on AUD remission. Results. In all, 64/312 (21%) subjects achieved remission during the study period. The presence of a severe mental disorder, such as delirium tremens and organic disorders, was related to remission. Blue-collar workers had higher rates of remission than white-collar workers. There was indication that treatment improved the prognosis. Conclusions. The overall remission rate was low, but treatment may improve the prognosis. Severe mental disorders, such as delirium tremens and organic disorders as well as being blue-collar rather than white-collar worker, were related to remission

Kinesiophobia and its association with functional outcome and quality of life 6-8 years after total hip arthroplasty

Objective: The aim of this study was to assess the incidence and severity of kinesiophobia, and to determine the relationship between Tampa Scale of Kinesiophobia (TSK) scores, functional outcome and quality of life (QoL) 6-8 years after Total Hip Arthroplasty (THA). Methods: 161 patients (78 male and 83 female) with unilateral primary osteoarthritis (OA) treated with THA between September 2010 and December 2013 were included in this study. Western Ontario and McMaster Universities Osteoarthritis (WOMAC) and EQ-5D scores were measured preoperatively. At 6-8 years follow-up, these scores were repeated and TSK scores were also measured. According to the TSK, patients were divided into two groups for further comparisons and analysis: without kinesiophobia (TSK-score ≤ 36) and with kinesiophobia (TSK-score >36). Results: There were 99 patients (61.5%) with no kinesiophobia (TSK score ≤ 36, TSK mean 28.4, SD 4.7) and 62 patients (38.5%) with kinesiophobia (TSK score > 36, TSK mean 42.8, SD 5.3). Patients with and without kinesiophobia were not statistically different regarding age, sex or body mass index. (P = 0.20, P = 0.99, P = 0.22, respectively). In the group with no kinesiophobia, the mean 6-8 years WOMAC was 12.4 (SD 15.6), while the absolute delta (Δ) value between preoperative and 6-8 years WOMAC was 46.2 (SD 20.4), compared to the group with kinesiophobia where the mean 6-8 years WOMAC was 32.2 (SD 23.4), while the absolute delta (Δ) value between preoperative and 6-8 years WOMAC was 32.3 (SD 25.5): both P < 0.001. The group with no kinesiophobia had a mean 6-8 years EQ-5D of 0.81 (SD 0.22), while the absolute delta (Δ) value between preoperative and 6-8 years EQ-5D was 0.44 (SD 0.26), compared to the group with kinesiopho-bia where the mean 6-8 years EQ-5D was 0.57 (SD 0.23), while the absolute delta (Δ) value between preoperative and 6-8 years EQ-5D was 0.33 (SD 0.26): P < 0.001 and P = 0.03, respectively. TSK scores were associated with worse WOMAC and EQ-5D scores, higher proportion of dependence on walking aids and increased THArelated adverse events (all P < 0.05). Conclusion: This study has shown us that there is a high incidence of kinesiophobia 6-8 years after surgery and treating kinesiophobia early after THA might improve the outcome. Level of Evidence: Level IV, Therapeutic Study

Lynx predation on semi-domestic reindeer: do age and sex matter?

The Eurasian lynx is an efficient stalking predator mainly selecting small-sized ungulates. In northern Scandinavia, semi-domestic reindeer are the only ungulate species available for Eurasian lynx year round and consequently constitute their main prey. Selective predation patterns by a predator on a domestic prey are likely to be influenced by husbandry practices and may have consequences for harvest strategies. We used data on 795 lynx-killed reindeer from northern Scandinavia collected in 2008–2011 to determine whether male and female Eurasian lynx preyed selectively on different age and sex classes of reindeer and how this was influenced by human-controlled seasonal changes in the composition of the reindeer herds. Lynx of both sexes were selected for reindeer calves year round although the proportions fluctuated seasonally, with peaks during summer and a drop after harvest. Male lynx switched to kill more adult reindeer in winter. There were no differences between the sexes of reindeer calves killed by lynx, but among adult reindeer male lynx selected for bulls over cows. We suggest that humancontrolled seasonal variation in reindeer abundance is a main driver of prey selection by Eurasian lynx on semi-domestic reindeer. conflict; domestic prey; Lynx lynx; predation; prey selection; Rangifer tarandus.publishedVersio

Lundbystudien 1972

The Lundby study is a classic psychiatric epidemiological population study conducted in 1947 in Dalby and Bonderups outside Lund. The follow-up examinations during 1957, 1972 and 1997 included those still living in Dalby and Bonderups, those who moved in during 1957 and those who moved out during 1957, 1972 and 1997. The Lundby study has produced data on the occurrence of new cases of psychiatric diseases in the population. The cohort can be used to relate changes in mental health to the individual circumstances and to society from 1947 to 1997. It is also well suited for studying the progression of common mental disorders such as depression, anxiety and dementia and mental disorders with long latency (e.g. psychosis). Interview data was supplemented by hospital records, registry data, and information from key people (family members, relatives and healthcare professionals). Loss of participation in the Lundby study has been very low, especially between 1947 and 1972. The Research Council grant funds have been used to digitalise the data. The archive is now kept at the Archives Center South in Lund. Purpose: The main purpose with the first Lundbystudy, performed in 1947, was to do a population study describing all the residents in Dalby and Bonderup (municipalities outside the city of Lund, not known for unusual high prevalence of illness and not geographical isolated) regarding personality traits, psychiatric diseases or and physical diseases. Follow-up studies, both new residents in 1957, remain living and expatriates, were conducted in 1957, 1972 and 1997.Lundbystudien är en klassisk psykiatrisk, epidemiologisk befolkningsstudie som genomfördes 1947 i Dalby och Bonderups socknar utanför Lund. Uppföljningsundersökningarna 1957,1972 och 1997 inkluderade de som bodde kvar i Dalby och Bonderups socknar, de som flyttat in 1957 och de som flyttat ut 1957, 1972 och 1997. Lundbystudien har producerat data om förekomst av och nyinsjuknande i psykisk ohälsa i befolkningen. Kohorten kan användas för att relatera förändringar i psykisk hälsa till individuella förutsättningar och till samhällsutvecklingen 1947-1997. Den är även väl lämpad för att studera förlopp av vanliga psykiska störningar som depression, ångest och demens samt psykiska störningar med lång latens (t.ex. psykos). Intervjudata har kompletterats med sjukhusjournaler, registerdata och information från nyckelpersoner (anhöriga, släktingar och vårdpersonal). Bortfallet i Lundbystudien har varit mycket lågt, framför allt mellan 1947 och 1972. Av Vetenskapsrådet beviljade medel har använts för att digitalisera data. Arkivet slutförvaras nu på Arkivcentrum Syd i Lund. Syfte: Huvudsyftet med den första Lundbystudien, genomförd 1947, var att göra en befolkningsundersökning som beskrev alla invånarna i Dalby och Bonderup (socknar utanför Lund, som inte var kända för någon ovanlig eller hög sjuklighet och som inte var något geografiskt isolat) med avseende på personlighetsvarianter, psykisk sjukdom eller avvikelse samt fysiska sjukdomar. Uppföljande studier, av såväl nyinflyttade 1957, kvarboende och utflyttade, genomfördes 1957, 1972 och 1997 1972 intervjuades de 2827 probander som var i livet. Av dessa bodde 1424 personer kvar i Lundbyområdet. Även probander som dött sedan föregående undersökning följdes upp genom nyckelinformanter, journaler och register. Studiedeltagarna var i åldrarna 15-97 år