Functional outcome 3–6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation

Background To compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation. Methods In total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3–6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires. Results In total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046). Conclusions In multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation

Determinants of Health Status Three to Six Years After Surgical Treatment of Closed Ankle Fracture and Comparison with the General Population: A Historical Cohort Study

Background: The purposes of the present study were to identify the determinants of health status 3 to 6 years after open reduction and internal fixation (ORIF) for the treatment of closed ankle fracture and to compare the health status of patients who had undergone this procedure with that in the general population after adjusting for sociodemographic variables, body mass index (BMI), and smoking status. Methods: The present study was a historical cohort study combined with a postal survey. In total, 1,149 patients who underwent ORIF for the treatment of closed ankle fractures at 2 hospitals were eligible for chart review; 959 with lowenergy fractures were eligible for a postal survey, and 471 (49%) responded to the Short Form Health Survey-36 (SF-36) health status questionnaire and provided data on BMI. Determinants of the physical functioning (PF), physical component summary (PCS), and mental component summary (MCS) scores of the SF-36 were analyzed by means of multivariable linear regression analysis. The health status of patients with an ankle fracture (n = 471) was compared with that in a sample of the general population (n = 5,396) by means of multivariable regression. Results: Age, American Society of Anesthesiologists (ASA) class III, and complications following surgery were associated with PF and PCS scores, and a BMI of ‡30 kg/m2 and current smoking status was associated with PF and MCS scores. However, the PF, PCS, and MCS scores of patients with ankle fractures did not differ from those of the general population, with unstandardized regression coefficients of 0.25 (95% confidence interval [CI], –1.67 to 2.16; p = 0.80), 0.67 (95% CI, –0.35 to 1.70; p = 0.199), and –0.57 (95% CI, –1.63 to 0.49; p = 0.29), respectively. Conclusions: Age, ASA class III, and complications following surgery were associated with PF and PCS scores at 3 to 6 years after surgery for the treatment of closed ankle fractures. However, the health status of patients with ankle fractures did not differ from that in the general population after adjusting for differences in demographic variables, BMI, and smoking status

Evaluation of three patient reported outcome measures following operative fixation of closed ankle fractures

Background Several patient reported outcome measures (PROMs) are available for assessing the outcomes of ankle fracture but few have been compared for recommended measurement properties. This study compares the measurement properties of the Lower Extremity Function Scale (LEFS), Olerud Molander Ankle Score (OMAS) and Self-Reported Foot and Ankle Score (SEFAS) following ankle surgery. Methods The retrospective cohort study included 959 patients aged 18 years and over who underwent surgical treatment (ORIF) for unstable and closed ankle fractures in SE Norway. The PROMs were included in a postal questionnaire sent to patients’ homes in 2015, three years after surgery. Missing data, structural validity, internal consistency, test-retest reliability and validity were assessed. Results Confirmatory factor analysis results showed model fit for the SEFAS and a bi-dimensional LEFS with scales of easy and difficult items. The OMAS performed less satisfactorily. Cronbach’s alpha and test-retest correlations ranged from 0.82 to 0.96 and 0.91 to 0.93 respectively. The smallest detectable differences for group and individual comparisons were 14.1 to 20.6 and 0.93 to 1.55; SEFAS performed best. As hypothesised, instrument scores were highly correlated and with those for the EQ-5D and SF-36 physical functioning. Mean imputation where half or more items are completed increased usable scores by 1.4–15.7% without affecting measurement properties. Conclusions The three instruments largely performed satisfactorily in relation to important measurement properties but the LEFS had evidence for two dimensions relating to easier and more difficult aspects of function. Mean imputation where half or more items are completed increased the number of usable responses for all three instruments. The three instruments represent different approaches to measuring outcomes and their content should be considered carefully when choosing between them. The SEFAS is designed for a range of foot disorders including ankle fractures and has the best measurement properties in this population

Low bone density and high morbidity in patients between 55 and 70 years with displaced femoral neck fractures: A case-control study of 50 patients vs 150 normal controls

Background A displaced femoral neck fracture (FNF) in patients 55-70 years is a serious injury with a high risk of treatment failure and the optimal surgical treatment remains unclear. We aimed to describe characteristics of fracture patients compared to a sample from the normal population. Methods Fifty patients aged 55-70 years with a displaced FNF were gender- and age- matched with a control group of 150 persons without a hip fracture using computergenerated randomization and the Norwegian National Population Register. To reduce the risk of spurious selection bias, the sample size of the control group was trebled compared to the fracture group. Dual-energy x-ray absorptiometry (DXA) was performed. Demographics and hip function (Harris Hip Score, Oxford Hip Score, and Hip Dysfunction and Osteoarthritis Outcome Score) were collected. Results There were more than 75% women in both groups. The mean age was 64.5 years in the fracture group and 65.1 in the control group. Results for DXA measured for lumbar spine, total hip and the femoral neck showed that patients with displaced FNF were significantly more osteoporotic. Fracture patients had significantly lower body mass index, higher Charlson comorbidity index (CCI), and higher ASA (American Society of Anesthesiologists) score than the control group. No clinically relevant differences in hip function were found. There were 48% smokers in the fracture group compared to 10% in the control group. The odds ratio for obtaining a displaced FNF was high if the patients suffered from osteoporosis, smoked or had several comorbidities. Conclusions This study showed that patients aged 55-70 years with a displaced femoral neck fracture had lower bone density and higher comorbidity compared with a gender- and age-matched population without femoral neck fractures. This suggests that this patient group is epidemiologically similar to older patients with femoral neck fractures

High failure rate after internal fixation and beneficial outcome after arthroplasty in treatment of displaced femoral neck fractures in patients between 55 and 70 years : An observational study of 2,713 patients reported to the Norwegian Hip Fracture Register

Background and purpose — The treatment of patients between 55 and 70 years with displaced intracapsular femoral neck fracture remains controversial. We compared internal fixation (IF), bipolar hemiarthroplasty (HA) and total hip arthroplasty (THA) in terms of mortality, reoperations and patient-reported outcome by using data from the Norwegian Hip Fracture Register. Patients and methods — We included 2,713 patients treated between 2005 and 2012. 1,111 patients were treated with IF, 1,030 with HA and 572 patients with THA. Major reoperations (defined as re-osteosynthesis, secondary arthroplasty, exchange, or removal of prosthesis components and Girdlestone procedure), patient-reported outcome measures (satisfaction, pain, and health-related quality of life (EQ5D) after 4 and 12 months), 1-year mortality, and change in treatment methods over the study period were investigated. Results — Major reoperations occurred in 27% after IF, 3.8% after HA and 2.8% after THA. 549 patients (20% of total study population) answered both questionnaires. Compared with IF, patients treated with THA were more satisfied after 4 and 12 months, reported less pain after 4 months and 12 months, had a higher EQ5D-index score after 4 months and 12 months, and EQ-VAS score after 4 months. Compared with IF, patients treated with HA were more satisfied and reported less pain after 4 months. EQ5D-index and EQ-VAS were similar. Patients treated with HA had higher 1-year mortality and had more comorbidities than both the THA and IF group. All these differences were statistically and clinically significant. Interpretation — This study showed high reoperation rate after IF and better patient-reported outcome after both THA and HA with medium follow-up. Patients selected for HA represented a frailer group than patients treated with THA or IF

Low bone density and high morbidity in patients between 55 and 70 years with displaced femoral neck fractures: a case-control study of 50 patients vs 150 normal controls

Background A displaced femoral neck fracture (FNF) in patients 55-70 years is a serious injury with a high risk of treatment failure and the optimal surgical treatment remains unclear. We aimed to describe characteristics of fracture patients compared to a sample from the normal population. Methods Fifty patients aged 55-70 years with a displaced FNF were gender- and age- matched with a control group of 150 persons without a hip fracture using computergenerated randomization and the Norwegian National Population Register. To reduce the risk of spurious selection bias, the sample size of the control group was trebled compared to the fracture group. Dual-energy x-ray absorptiometry (DXA) was performed. Demographics and hip function (Harris Hip Score, Oxford Hip Score, and Hip Dysfunction and Osteoarthritis Outcome Score) were collected. Results There were more than 75% women in both groups. The mean age was 64.5 years in the fracture group and 65.1 in the control group. Results for DXA measured for lumbar spine, total hip and the femoral neck showed that patients with displaced FNF were significantly more osteoporotic. Fracture patients had significantly lower body mass index, higher Charlson comorbidity index (CCI), and higher ASA (American Society of Anesthesiologists) score than the control group. No clinically relevant differences in hip function were found. There were 48% smokers in the fracture group compared to 10% in the control group. The odds ratio for obtaining a displaced FNF was high if the patients suffered from osteoporosis, smoked or had several comorbidities. Conclusions This study showed that patients aged 55-70 years with a displaced femoral neck fracture had lower bone density and higher comorbidity compared with a gender- and age-matched population without femoral neck fractures. This suggests that this patient group is epidemiologically similar to older patients with femoral neck fractures

Cross-Table Lateral Radiographs Accurately Predict Displacement in Valgus-Impacted Femoral Neck Fractures

Background: Femoral neck fractures are classified as nondisplaced (Garden types I and II) or displaced (Garden types III and IV) on the basis of anteroposterior radiographs. Cross-table lateral radiographs are important in the assessment of Garden type-I and II fractures as posterior tilt of the femoral head may influence treatment results. A posterior tilt of >20° has been associated with an increased risk of treatment failure after internal fixation, although the precision of these measurements has not been validated. Therefore, the purpose of the present study was to compare cross-table lateral radiographs with 3-dimensional computed tomographic (3D-CT) reconstructions of Garden type-I and II femoral neck fractures. Methods: Twenty-three patients presenting with Garden type-I and II femoral neck fractures that were verified on anteroposterior radiographs underwent CT scanning immediately after radiographic examination. 3D models of the fractured and uninjured femora were reconstructed from the CT images, and displacement of the 3D models was determined by superimposing the fractured and uninjured femora. We defined a coordinate system with its origin at the center of the uninjured femoral head with the x axis oriented medially; the y axis, posteriorly; and the z axis, cranially. Correlations between lateral radiographs and 3D models were assessed with the Spearman rank coefficient, mean difference, and limits of agreement. Results: Posterior tilt of the femoral head on lateral radiographs was strongly correlated with displacement of the femoral head along the y axis of the 3D models, with a correlation coefficient of 0.86 (p < 0.001). Correlations between the findings on lateral radiographs and displacements along the x or z axis were weak, with coefficients of −0.30 (p = 0.18) and 0.21 (p = 0.34), respectively. The mean difference between displacement on lateral radiographs and displacement along the y axis of the 3D models was smaller, and demonstrated a smaller limits-of-agreement interval, compared with the x or z axis. Conclusions: Our results demonstrated a strong correlation between posterior displacement of the femoral head on lateral radiographs and displacement along the y axis in 3D models of Garden type-I and II femoral neck fractures. This finding indicates that lateral radiographs provide an accurate assessment of posterior tilt

Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures: 322 patients followed for a mean of 3 years

Background and purpose — It has been suggested that preoperative posterior tilt of the femoral head may increase the risk of fixation failure in Garden-I and -II femoral neck fractures. To investigate this association, we studied a cohort of 322 such patients. Patients and methods — Patients treated with internal fixation between 2005 and 2012 were retrospectively identified using hospital records and the digital image bank. 2 raters measured the preoperative posterior tilt angle and categorized it into 3 groups: < 10°, 10–20°, and ≥ 20°. The inter-rater reliability (IRR) was determined. Patients were observed until September 2013 (with a minimum follow-up of 18 months) or until failure of fixation necessitating salvage arthroplasty. The risk of fixation failure was assessed using competing-risk regression analysis, adjusting for time to surgery. Results — Patients with a posterior tilt of ≥ 20° had a higher risk of fixation failure: 19% (8/43) as compared to 11% (14/127) in the 10–20° category and 6% (9/152) in the < 10° category (p = 0.03). Posterior tilt of ≥ 20° increased the risk of fixation failure, with an adjusted hazard ratio of 3.4 (95% CI: 1.3–8.9; p = 0.01). The interclass correlation coefficient for angular measurements of posterior tilt was 0.90 (95% CI: 0.87–0.92), and the IRR for the categorization of posterior tilt into 3 groups was 0.76 (95% CI: 0.69–0.81). Interpretation — Preoperative posterior tilt of ≥ 20° in Garden-I and -II femoral neck fractures increased the risk of fixation failure necessitating salvage arthroplasty. The reliability of the methods that we used to measure posterior tilt ranged from good to excellent

Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures: 322 patients followed for a mean of 3 years

Background and purpose — It has been suggested that preoperative posterior tilt of the femoral head may increase the risk of fixation failure in Garden-I and -II femoral neck fractures. To investigate this association, we studied a cohort of 322 such patients. Patients and methods — Patients treated with internal fixation between 2005 and 2012 were retrospectively identified using hospital records and the digital image bank. 2 raters measured the preoperative posterior tilt angle and categorized it into 3 groups: < 10°, 10–20°, and ≥ 20°. The inter-rater reliability (IRR) was determined. Patients were observed until September 2013 (with a minimum follow-up of 18 months) or until failure of fixation necessitating salvage arthroplasty. The risk of fixation failure was assessed using competing-risk regression analysis, adjusting for time to surgery. Results — Patients with a posterior tilt of ≥ 20° had a higher risk of fixation failure: 19% (8/43) as compared to 11% (14/127) in the 10–20° category and 6% (9/152) in the < 10° category (p = 0.03). Posterior tilt of ≥ 20° increased the risk of fixation failure, with an adjusted hazard ratio of 3.4 (95% CI: 1.3–8.9; p = 0.01). The interclass correlation coefficient for angular measurements of posterior tilt was 0.90 (95% CI: 0.87–0.92), and the IRR for the categorization of posterior tilt into 3 groups was 0.76 (95% CI: 0.69–0.81). Interpretation — Preoperative posterior tilt of ≥ 20° in Garden-I and -II femoral neck fractures increased the risk of fixation failure necessitating salvage arthroplasty. The reliability of the methods that we used to measure posterior tilt ranged from good to excellent