The incidence of pelvic fractures and related surgery in the Finnish adult population: a nationwide study of 33,469 patients between 1997 and 2014

Background and purpose — Information on the epidemiological trends of pelvic fractures and fracture surgery in the general population is limited. We therefore determined the incidence of pelvic fractures in the Finnish adult population between 1997 and 2014 and assessed the incidence and trends of fracture surgery.Patients and methods — We used data from the Finnish National Discharge Register (NHDR) to calculate the incidence of pelvic fractures and fracture surgery. All patients 18 years of age or older were included in the study. The NHDR covers the whole Finnish population and gives information on health care services and the surgical procedures performed.Results and interpretation — We found that in Finnish adults the overall incidence of hospitalization for a pelvic fracture increased from 34 to 56/100,000 person-years between 1997 and 2014. This increase was most apparent for the low-energy fragility fractures of the elderly female population. The ageing of the population is likely therefore to partly explain this increase. The annual number and incidence of pelvic fracture surgery also rose between 1997 and 2014, from 118 (number) and 3.0 (incidence) in 1997 to 187 and 4.3 in 2014, respectively. The increasing number and incidence of pelvic fractures in the elderly population will increase the need for social and healthcare services. The main focus should be on fracture prevention.

Pelvic fractures range from minor to major trauma and constitute about 3% to 8% of all fractures treated in hospitals (Court-Brown and Caesar 2006). The incidence of pelvic fractures has varied from 17 to 364/100,000 person-years (Melton et al. 1981, Ragnarsson and Jacobsson 1992, Lüthje et al. 1995, Kannus et al. 2000, Balogh et al. 2007, Andrich et al. 2015, Kannus et al. 2015, Verbeek et al. 2017). This wide range in incidence rates can be explained by different study populations with varying age, and by variations in study designs and follow-up periods. In previous studies, the incidence (n/100,000 person-years) of pelvic fractures was in the United States 37 between 1968 and 1977 (Melton et al. 1981), in Sweden 20 between 1976 and 1985 (Ragnarsson and Jacobsson 1992), in Finland 24 in 1988 (Lüthje et al. 1995), in the Finnish population aged 60 years or older 20 in 1970 and 92 in 1997 (Kannus et al. 2000), in Australia 23 between 2005 and 2006 (Balogh et al. 2007), in the German population aged 60 years or older 22 between 2008 and 2011 (Andrich et al. 2015), in the Finnish population aged 80 years or older 73 in 1971 and 364 in 2013 (Kannus et al. 2015) and in the Netherlands 14 between 2008 and 2012 (Verbeek et al. 2017).In the 80 years and older population, the incidence of low-energy pelvic fractures seems to be increasing (Kannus et al. 2015). Indeed, between 1997 and 2014, the incidence of acetabular fractures, especially low-energy acetabular fractures, rose in Finland (Rinne et al. 2017), whereas the incidence of high-energy acetabular fractures remained at the same level. Notably, since 1997, the incidence of many other fall-related low-energy fractures, such as hip fractures, has decreased in Finland (Korhonen et al. 2013, Kannus et al. 2018).Most pelvic fracture studies concentrate on surgical treatment, even though the majority of these fractures can be treated nonoperatively (Osterhoff et al. 2019, Tornetta et al. 2019). Unstable and dislocated pelvic fractures often need surgery, while stable, non-displaced, or minimally displaced fractures, mostly occurring in elderly people after a simple fall, can usually be treated nonsurgically. At present, however, there is only limited information available regarding the incidence and trends of pelvic fracture surgery in the general population.We assessed the incidence of pelvic fractures in the Finnish adult population between 1997 and 2014 and the incidence and trends of pelvic fracture surgery.     

How deadly is a fracture distal to the hip in the elderly? An observational cohort study of 11,799 femoral fractures in the Swedish Fracture Register

Background and purpose — Unlike hip fractures, diaphyseal and distal femoral fractures in elderly patients have not been widely studied. We investigated the demographics, comorbidities and mortality of patients with femoral fractures at any anatomical level with a focus on early mortality.Patients and methods — We analyzed 11,799 patients ≥ 65 years with a femoral fracture registered in the Swedish Fracture Register from 2011 to 2014. The cohort was matched with the National Patient Register to obtain data on comorbidities classified according to the Charlson Comorbidity Index (CCI). Generalized linear models were fitted to estimate the adjusted relative risk of mortality.Results — Mean age of the cohort was 83 years and 69% were women. Patients with distal femoral fractures had the lowest degree of comorbidity, with 9% having a CCI of ≥ 3 compared with 14% among those with proximal and 16% among those with diaphyseal fractures. Unadjusted 90-day mortalities were 13% (95% CI 9.4–16) after fractures in the distal, 13% (CI 10–16) in the diaphyseal, and 15% (CI 14–15) in the proximal segment. The adjusted relative risk for 90-day mortality was 1.1 (CI 0.86–1.4) for patients with distal and 0.97 (CI 0.76–1.2) for patients with diaphyseal femoral fractures when compared with patients with hip fractures.Interpretation — Elderly patients with femoral fractures distal to the hip may have similar adjusted early mortality risks to those with hip fractures. There is a need for larger, preferably prospective, studies investigating the effect of rapid pathways and geriatric co-management for patients with diaphyseal and distal femoral fractures.

1-year mortality after proximal femur fractures is up to 30% and is higher in men (Do et al. 2016, Mattisson et al. 2018). Proximal femoral fractures have been thoroughly investigated for outcomes after different treatment modalities (Gdalevich et al. 2004, Sircar et al. 2007, Al-Ani et al. 2008, Khan et al. 2009, Hansson et al. 2017, Bartels et al. 2018, Dolatowski et al. 2019).In contrast, little research has been conducted on femoral fractures distal to the proximal segment in the elderly population. However, there is some evidence to suggest that patients with diaphyseal and distal femur fractures have similar mortality and mobility risks to those with proximal femur fractures (Konda et al. 2015, Myers et al. 2018, Larsen et al. 2020). Elderly patients with fractures of the femur distal to the hip also seem to be similar to hip fracture patients in age and sex distribution. However, there is little information on their degree of comorbidities (Smith et al. 2015) and, to our knowledge, no comparative study has been performed on mortality after femoral fractures distal to the hip. Consequently, guidelines are lacking on the treatment of elderly patients with diaphyseal and distal femoral fractures.The Swedish Fracture Register (SFR) was launched in 2011 to prospectively monitor fracture treatment performed in Sweden and collect information on all fractures, including data on injury mechanisms, fracture characteristics, and treatments (Wennergren et al. 2015). Data from this register has been matched with the National Patient Register (NPR) to obtain information on comorbidities and causes of death (Ludvigsson et al. 2009). We thus designed an observational study on a cohort of elderly patients with femoral fractures with the primary aim to evaluate the association of fracture localization with mortality, adjusting for pre-existing comorbidities.     

The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures

Background and purpose — The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality.Patients and methods — In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson’s criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed.Results — The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3–2.7), when adjusted for confounders.Interpretation — The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.

The bone cement implantation syndrome (BCIS) is a well-recognized and potentially fatal complication of orthopedic surgery involving pressurized bone cement (Donaldson et al. 2009). The syndrome is mostly noted in cemented hemiarthroplasty after displaced femoral neck fractures, but is also found in total hip and knee replacement surgery (Byrick et al. 1986, Clark et al. 2001). This syndrome is characterized by hypoxia, systemic hypotension, pulmonary hypertension, arrhythmias, loss of consciousness, and cardiac arrest (Clark et al. 2001, Kotyra et al. 2010).The pathophysiology of BCIS is unclear, but anaphylaxis, inflammatory, thermic and complement activation (Dahl et al. 1988) have all been implicated to induce BCIS (Donaldson et al. 2009). Studies employing invasive hemodynamic monitoring and perioperative ultrasound imaging have revealed subclinical pulmonary embolisms and hemodynamic changes, not detected in standard intra- and postoperative monitoring (Orsini et al. 1987, Bisignani et al. 2008, Kotyra et al. 2010).Until recently, the incidence of BCIS in cemented hemiarthroplasty for hip fractures has been unknown, mainly because a consensual definition of the BCIS syndrome has been lacking. Donaldson et al. (2009) defined a severity classification of BCIS (Grade 1, 2, and 3). In a previous study on patients undergoing cemented hemiarthroplasty for hip fractures, we found that the incidence for all grades of BCIS was 28%, with a huge impact on early and late mortality (Olsen et al. 2014).In this study, we evaluated the role of the cementation, per se, for the development of hypotension and hypoxia and its impact on mortality in patients undergoing hemiarthroplasty for femoral neck fractures. To enable this, a multitude of risk factors influencing mortality were collected in order to isolate the cementation effect. Our hypothesis was that the use of bone cement is an independent risk factor for postoperative mortality.     

Socioeconomic position is associated with surgical treatment of open fractures of the lower limb: results from a Swedish population-based study

Background and purpose — High-energy trauma to the lower limbs can result in open fractures, treated by reconstructive surgery or amputation. We examined whether socioeconomic position is associated with choice of primary treatment.Patients and methods — We performed a nationwide population-based study using the Swedish National Patient Register to identify all adult patients who between 1998 and 2013 underwent reconstruction or amputation after an open fracture below the knee. Information on socioeconomic position was collected from Statistics Sweden.Results — Of 275 individuals undergoing surgery after an open fracture below the knee during the study period, the 1st surgery was reconstructive in 58% of the patients and amputation in 42%. The chance of having an initial reconstruction was lower for women than for men (OR 0.5, 95% CI 0.3–0.9), lower with age (OR 0.97, CI 0.96–0.99), and lower for individuals without employment compared with individuals in employment (OR 0.3, CI 0.2–0.5). Primary treatment was in women associated with family composition, whereas in men it was associated with level of education.Interpretation — Choice of primary treatment after open fracture in the lower limb is affected by socioeconomic position including sex, age, employment, family composition, level of education, and income.

In Sweden the prevalence of open tibia fractures is around 220 per year of which around one-third are classified as Gustilo–Anderson III (Weiss et al. 2008, Tampe et al. 2014). Similar incidences of open tibia fractures have been shown in studies on other populations (Court-Brown et al. 2012).Outcomes are poor for reconstructed and amputated patients alike, and in terms of function and pain do not necessarily differ between reconstruction and amputation (Bosse et al. 2002, Busse et al. 2007, Akula et al. 2011, Soni et al. 2012). Nearly half of patients treated for an open lower limb fracture will end up with a decreased range of motion, and little more than half of the patients are able to return to work (Busse et al. 2007, Soni et al. 2012, Barla et al. 2017). Reconstruction of the limb is easier for patients to accept, and may be preferred (Akula et al. 2011).Scoring systems such as the Ganga Hospital Open Injury Score (GHOISS) and the Mangled Extremity Severity Score (MESS) are available to guide the treating surgeon in the decision-making process, and account for the degree of tissue damage as well as other patient-related factors (Helfet et al. 1990, Rajasekaran et al. 2015). However, the utility of such scoring systems has been questioned (Ly et al. 2008, Loja et al. 2017). Long-term outcomes also appear to be affected by patient-related factors such as socioeconomic position and personal resources (MacKenzie et al. 2006, Driesman et al. 2017).Socioeconomic position, such as sex, level of education, income, family composition, and immigrant status, has in other healthcare areas been connected to incidence and outcome of disease (Woodward et al. 2015, Abdoli et al. 2017, Zommorodi et al. 2019). Furthermore, socioeconomic position, as determined by income and education, has been shown to affect the likelihood of undergoing operative treatment after a cruciate ligament injury in Sweden (Nordenvall et al. 2017). We examined whether determinants of socioeconomic position are associated with choice of primary treatment in patients with open fractures of the lower extremity.     

Development of the annual incidence rate of fracture in children 1980–2018: a population-based study of 32,375 fractures

Background and purpose — Pediatric fractures are a common cause of morbidity. So far, no larger Danish study has described the development in the incidence rates. Therefore, we describe the development in the incidence rates of pediatric fractures in the time period 1980–2018 and the frequency of the most common type of fractures.Patients and methods — This is a retrospective register study of all children aged 0–15 years with a fracture treated in the Emergency Department at Odense University Hospital, Denmark, between 1980 and 2018. For all cases, information on age, sex, date of treatment, diagnosis, and treatment was obtained from the patient registration system. Based on official public population counts we estimated age and sex-specific annual incidence rates.Results — 32,375 fractures were included. In the study period the incidence rate decreased by 12%. The incidence increased until the early 1990s. Thereafter incidence rates decreased until 2004–09, from then onward increasing towards the end of the study period. The highest age-specific incidence rate in boys of 522 per 10,000 person-years was at 13 years of age. In girls the age of the highest incidence rate decreased from 11 years in 1980 to 10 years in 2018. Fracture of the lower end of the forearm, the clavicle, and the lower end of the humerus had the highest single fracture incidence rates.Interpretation — The incidence rate of pediatric fractures decreased in the study period by 12%. The highest single fracture incidence rates were for fracture of the lower end of the forearm, the clavicle, and the lower end of the humerus. As the first longitudinal Danish study of pediatric fractures this study is a baseline for evaluating future interventions and future studies.

Injuries are one of the leading causes of morbidity in children and are the leading cause of admission to the healthcare system. In 2018 more than 300,000 children and adolescents were treated in Danish Emergency Departments because of injuries (Statistics Denmark 2018).Previous studies have found that the overall risk of sustaining a fracture during childhood is 10–25% (Sibert et al. 1981, Landin 1983, Cheng and Shen 1993, Landin 1997). Additionally, the lifetime risk of sustaining a fracture is 27% and 42% for girls and boys respectively (Landin 1997). In a study from Hong Kong the lifetime risk of hospitalization due to a pediatric fracture was 7% (Cheng and Shen 1993).Studies have demonstrated variations in the incidence rate of childhood fractures. In Sweden an increase in the incidence rate of pediatric fractures was found from 1950 to 1979 (Landin 1983, 1997). A similar increase was found in Finland from 1967 to 1983 (Mäyränpää et al. 2011). Conversely, during the 1980s the incidence rate decreased in these countries (Tiderius et al. 1999, Mäyränpää et al. 2011). Since 1993 different trends have been found in incidence rates as an increase was found in Sweden while a continued decrease was found in Finland (Hedström et al. 2010, Mäyränpää et al. 2011).Only 1 recent study has described the changes in the incidence rates of pediatric fractures (Lempesis et al. 2017). This Swedish study found a decrease in the fracture incidence rate in girls from 1993–1994 to 2005–2006, but not in boys. So far, no other recent longitudinal population-based study of the variation in the incidence rates of pediatric fractures has been published.We describe the development in the incidence rates of pediatric fractures in the period 1980–2018 and describe the frequency and changes of most common type of fractures.     

Mortality and revision rate of cemented and uncemented hemiarthroplasty after hip fracture: an analysis of the Dutch Arthroplasty Register (LROI)

Background and purpose — Femoral neck fractures are commonly treated with cemented or uncemented hemiarthroplasties (HA). We evaluated differences in mortality and revision rates in this fragile patient group.Patients and methods — From January 1, 2007 until December 31, 2016, 22,356 HA procedures from the Dutch Arthroplasty Register (LROI) were included. For each HA, follow-up until death, revision, or end of follow-up (December 31, 2016) was determined. The crude revision rate was determined by competing risk analysis. Multivariable Cox regression analyses were performed to evaluate the effect of fixation method (cemented vs. uncemented) on death or revision. Age, sex, BMI, Orthopaedic Data Evaluation Panel (ODEP) rating, ASA grade, surgical approach, and previous surgery were included as potential confounders.Results — 1-year mortality rates did not differ between cemented and uncemented HA. 9-year mortality rates were 53% (95% CI 52–54) in cemented HA compared to 56% (CI 54–58) in uncemented HA. Multivariable Cox regression analysis showed similar mortality between cemented and uncemented HA (HR 1.0, CI 0.96–1.1). A statistically significantly lower 9-year revision rate of 3.1% (CI 2.7–3.6) in cemented HA compared with 5.1% (CI 4.2–6.2) in the uncemented HA was found with a lower hazard ratio for revision in cemented compared with uncemented HA (HR 0.56, CI 0.47–0.67).Interpretation — Long-term mortality rates did not differ between patients with a cemented or uncemented HA after an acute femoral neck fracture. Revision rates were lower in cemented compared with uncemented HA.

The number of hemiarthroplasties (HA) after displaced femoral neck fracture increases as a result of global aging, and inferior results and high risk of reoperation after internal fixation. Although the literature on the decision to use cemented or uncemented HA may favor a cemented implant, both techniques are currently used. The use of bone cement is associated with bone cement implantation syndrome (BCIS) characterized by hypoxia, hypotension, loss of consciousness around the time of bone cementation, and intraoperative death (Olsen et al. 2014, Rutter et al. 2014). More intraoperative complications including intraoperative death were found in cemented HA in the Norwegian register (Gjertsen et al. 2012, Talsnes et al. 2013). However, no differences in mortality were found after 1 week (Costain et al. 2011, Yli-Kyyny et al. 2014). More studies including randomized controlled trials (Deangelis et al. 2012, Taylor et al. 2012) and registry studies (Costa et al. 2011, Ekman et al. 2019) did not show differences in mortality between cemented and uncemented HA. Randomized controlled trials (Taylor et al. 2012, Langslet et al. 2014, Inngul et al. 2015) and register studies (Gjertsen et al. 2012, Yli-Kyyny et al. 2014) have shown that the use of uncemented implants could result in a higher risk of periprosthetic fractures. A meta-analysis by Li et al. (2013) concluded that differences in several outcome parameters indicated cemented hemiarthroplasty to be superior to the uncemented counterpart. However, a serious flaw in this analysis is that several studies were included using an outdated stem like the Austin Moore (Sonne-Holm et al. 1982, Emery et al. 1991, Parker et al. 2010) and the experimental uncemented Thomson stem (Sadr and Arden 1977). The use of a prosthesis without Orthopaedic Data Evaluation Panel (ODEP) rating > 3A could influence outcome and is therefore discouraged (Grammatopoulos et al. 2015). A recent review by Rogmark and Leonardsson (2016) included 5 randomized studies comparing modern uncemented and cemented hemiarthroplasties. They found no differences in mortality, but more periprosthetic fractures in uncemented cases. We compared cemented and uncemented HA after an acute hip fracture with primary outcome mortality and revision rate. Data from the Dutch Arthroplasty Register (LROI) were used and the cohort of cemented HAs was compared with uncemented HAs, accounting for the ODEP rating and other confounders.     

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study

Background and purpose — Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods — The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results — 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29–32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12–14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation — Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

It is estimated that approximately 40% of all ankle fractures require surgical management, most commonly open reduction and internal fixation (ORIF) (Jensen et al. 1998). According to Kannus et al. (2016), an earlier increasing trend in the incidence of ankle fractures in Finland has steadied.Ankle fractures are associated with high costs related not only to the operation and subsequent hospitalization, but also to the duration of occupational disability (Stull et al. 2017). To reduce the costs of occupational disability, an early return to previous activities and the avoidance of secondary operations is crucial. In a recent study, Fenelon et al. (2019) found that 13% of patients who had had ankle fracture surgery in Ireland underwent hardware removal. The most common reason was planned removal (6%) followed by symptomatic hardware (6%), and infection (0.5%). The reasons for hardware removal include pain and soft tissue irritation, deep late infection, metal allergy or toxicity, hardware migration, metal failure, and secondary fracture (Bostman and Pihlajamaki 1996). The hardware removal rates reported by previous studies have varied between 12% and 80% (Richards et al. 1992, Sanderson et al. 1992, Bostman and Pihlajamaki 1996).While the removal of hardware after ankle fracture surgery is often a straightforward procedure, complication rates are still as high as 10–20% (Sanderson et al. 1992, Kasai et al. 2019). Patient satisfaction and symptomatic relief following ankle fracture surgery is also controversial (Jamil et al. 2008, Williams et al. 2012). Postoperative complications include infections, impaired wound healing, refractures, tissue and nerve damage, postoperative bleeding, and incomplete removal (Sanderson et al. 1992).We determined the incidence and trends in Finland of ankle fracture surgery and hardware removal after ORIF of ankle fractures on a national level. Additionally, we estimated the costs and economic burden of the removal and surgery itself.     

Is there a reduction in risk of revision when 36-mm heads instead of 32 mm are used in total hip arthroplasty for patients with proximal femur fractures?: A matched analysis of 5,030 patients with a median of 2.5 years’ follow-up between 2006 and 2016 in the Nordic Arthroplasty Register Association

Background and purpose — 32-mm heads are widely used in total hip arthroplasty (THA) in Scandinavia, while the proportion of 36-mm heads is increasing as they are expected to increase THA stability. We investigated whether the use of 36-mm heads in THA after proximal femur fracture (PFF) is associated with a lower risk of revision compared with 32-mm heads.Patients and methods — We included 5,030 patients operated with THA due to PFF with 32- or 36-mm heads from the Nordic Arthroplasty Register Association database. Each patient with a 36-mm head was matched with a patient with a 32-mm head, using propensity score. The patients were operated between 2006 and 2016, with a metal or ceramic head on a polyethylene bearing. Cox proportional hazards models were fitted to estimate the unadjusted and adjusted hazard ratio (HR) with 95% confidence intervals (CI) for revision for any reason and revision due to dislocation for 36-mm heads compared with 32-mm heads.Results — 36-mm heads had an HR of 0.9 (CI 0.7–1.2) for revision for any reason and 0.8 (CI 0.5–1.3) for revision due to dislocation compared with 32-mm heads at a median follow-up of 2.5 years (interquartile range 1–4.4).Interpretation — We were not able to demonstrate any clinically relevant reduction of the risk of THA revision for any reason or due to dislocation when 36-mm heads were used versus 32-mm. Residual confounding due to lack of data on patient comorbidities and body mass index could bias our results.

During the past years total hip arthroplasty (THA) has become the preferred treatment option for displaced femoral neck fractures in even younger (55–64 years) patients (Rogmark et al. 2017). Previous studies have shown an increased risk of revision, especially due to dislocation, in patients receiving THA after proximal femur fracture (PFF) compared with patients operated due to primary osteoarthritis (OA) (Conroy et al. 2008, Hailer et al. 2012). The risk of THA dislocation in fracture patients varies widely from as low as 5% (Tabori-Jensen et al. 2019), especially when dual mobility cups (DMCs) are used, up to 6–18% (Burgers et al. 2012, Johansson 2014, Noticewala et al. 2018) with conventional cups. The risk of THA revision due to dislocation has been reported as even lower, ranging from 0.5 to 0.7% in national register studies (Conroy et al. 2008, Hailer et al. 2012), as not all unstable THAs are revised. According to the above-mentioned studies, increased age, male sex, the use of a posterior approach, and smaller head sizes are associated with increased risk of revision due to dislocation. To counteract the risk of dislocation, bigger head sizes have been used as they increase the impingement-free range of motion (Burroughs et al. 2005, Tsuda et al. 2016) and jumping distance of THA (Sariali et al. 2009). During the past years, the use of larger heads in THA has increased with 28-mm continuously declining and 32- and 36-mm increasing (Tsikandylakis et al. 2018b). However, register studies performed on patients with displaced femoral neck fracture (Jameson et al. 2012, Cebatorius et al. 2015) have not demonstrated any superiority of larger heads over smaller ones regarding risk of revision, especially due to dislocation. This effect has only been demonstrated in studies performed on a case mix of hip diagnoses that have reported an increased risk of revision due to dislocation when 28-mm or smaller heads are used compared with 32-mm or larger heads (Hailer et al. 2012, Kostensalo et al. 2013).Most of the above-mentioned register studies have used 28-mm heads as reference, which are rarely used nowadays (Tsikandylakis et al. 2018b). Patients receiving THA after PFF have a higher risk for revision than patients with OA and should preferably be studied separately, setting 32 mm as contemporary standard of reference. We therefore investigated if increasing head size from 32 to 36 mm is associated with a decreased risk of revision, especially due to dislocation, in patients with PFF in the Nordic Arthroplasty Register Association (NARA) database. We hypothesized that the risk is lower when 36-mm heads are used.     

Surgical site infection after hip fracture – mortality and risk factors: an observational cohort study of 1,709 patients

Background and purpose — Surgical site infection (SSI) is a devastating complication of hip fracture surgery. We studied the contribution of early deep SSI to mortality after hip fracture surgery and the risk factors for deep SSI with emphasis on the duration of surgery.Patients and methods — 1,709 patients (884 hemi­arthroplasties, 825 sliding hip screws), operated from 2012 to 2015 at a single center were included. Data were obtained from the Norwegian Hip Fracture Register, the electronic hospital records, the Norwegian Surveillance System for Antibiotic Use and Hospital-Acquired Infections, and the Central Population Register.Results — The rate of early (≤ 30 days) deep SSI was 2.2% (38/1,709). Additionally, for hemiarthroplasties 7 delayed (> 30 days, ≤ 1 year) deep SSIs were reported. In patients with early deep SSI 90-day mortality tripled (42% vs. 14%, p < 0.001) and 1-year mortality doubled (55% vs. 24%, p < 0.001). In multivariable analysis, early deep SSI was an independent risk factor for mortality (RR 2.4 for 90-day mortality, 1.8 for 1-year mortality, p < 0.001). In univariable analysis, significant risk factors for early and delayed deep SSI were cognitive impairment, an intraoperative complication, and increasing duration of surgery. However, in the multivariable analysis, duration of surgery was no longer a significant risk factor.Interpretation — Early deep SSI is an independent risk factor for 90-day and 1-year mortality after hip fracture surgery. After controlling for observed confounding, the association between duration of surgery and early and delayed deep SSI was not statistically significant.

Hip fractures, in usually frail, elderly patients, have high mortality rates of around 9% within 30 days (Sheikh et al. 2017) and up to 30% within 1 year (Lund et al. 2014). If a deep surgical site infection (SSI) ensues, a 1-year mortality rate of 50% (Edwards et al. 2008) has been reported. However, it is not clear to what extent this increased mortality rate is due to the infection and the treatment thereof and to what extent it is due to a more pronounced frailty which predisposed these patients to SSI (Belmont et al. 2014).Considering the serious consequences of SSI for hip fracture patients it is important to optimize modifiable risk factors. However, reported risk factors differ, ranging from operative delay to the lead surgeon’s experience, duration of surgery, choice of implant, and patient factors such as obesity (Harrison et al. 2012, Cordero et al. 2016, de Jong et al. 2017, Zajonz et al. 2019).Duration of surgery is a risk factor commonly focused upon. However, the question remains as to whether longer duration of surgery increases the risk of SSI by prolonging exposure to possible bacterial contamination (Stocks et al. 2010) or if prolonged duration of surgery represents a surrogate parameter for a difficult procedure or a complication as the main cause for an increased risk of SSI.In this observational cohort study, we investigated the contribution of early deep SSI to mortality after hip fracture surgery and risk factors for early and delayed deep SSI in hip fracture patients with particular emphasis on the role of duration of surgery.     

No association between waiting time to surgery and mortality for healthier patients with hip fracture: a nationwide Swedish cohort of 59,675 patients

Background and purpose — Waiting time to surgery for patients with hip fractures and its potential association with mortality has been frequently studied with the hypothesis that longer waiting time is associated with adverse outcomes. However, despite numerous studies, there is no consensus regarding which time frames are appropriate, and whether some patients are more vulnerable to waiting than others. We explored the association between waiting time to surgery and short-term mortality and whether sex, age, surgical method, and comorbidity (ASA) modified this association.Patients and methods — This is a nationwide cohort study of 59,675 patients undergoing hip fracture surgery between January 1, 2013 and December 31, 2017 with a 4-month follow-up of mortality. Data were extracted from the Swedish Registry for Hip Fracture Patients and Treatment (RIKSHÖFT) and mortality was obtained from Statistics Sweden.Results — Unadjusted analyses revealed an association between waiting more than 24 hours for surgery and increased mortality, primarily for women. However, when stratifying for ASA grade, an association persisted only among patients with ASA 3 and 4. Furthermore, the absolute differences in mortality risk between those waiting less or longer than 24 hours were small. Age, fracture type, and surgical method did not modify the association between waiting time and mortality.Interpretation — This study suggests that there may be a need for new guidelines, which take into account the heterogeneity of the patient population.

Waiting time to surgery for patients with hip fractures has been studied with the hypothesis that longer waiting time is associated with adverse outcomes for those patients (Ryan et al. 2015, Morrisey et al. 2017, Hongisto et al. 2019). The underlying mechanism as to why prolonged waiting time to surgery would be detrimental is the longer immobilization with a following catabolism (Hedström et al. 2006) as well as the subsequent increased risk of complications. However, there is no consensus regarding what time frames are optimal, and what constitutes a “longer” waiting time varies widely in different studies (Lewis and Wadell 2016).In Sweden, the latest national guidelines prescribe that all patients should receive surgery within 24 hours (National Board of Health and Welfare 2003). Other countries have similar guidelines: the British National Clinical Guideline Centre (NICE) recommends surgery the same day or the day after hospital admission (NICE 2011). The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of hospital admission (AAOS 2014). One way to attempt to decrease waiting time to surgery is to institute “fast track care” for patients with hip fracture, often consisting of attempts at early recognition of the hip fracture and thereafter expedient admission to the hospital ward, sometimes bypassing the emergency room entirely (Larsson et al. 2016, Pollmann et al. 2019)It is not known how, and if, waiting longer than 24 hours for surgery was associated with increased mortality compared with waiting less than 24 hours for surgery for patients with hip fractures in Sweden in recent years. It is further possible that the inconsistent results in previous studies on the risks of adverse outcomes due to prolonged waiting time to surgery may be due to different population characteristics of the study subjects in different studies. Some patient groups may be more vulnerable to waiting than others, which calls for studies looking at subgroups separately.We explored the association between waiting time to surgery and the 4-month mortality risk in patients with a hip fracture in Sweden between 2013 and 2017, and whether sex, surgical method, age, and comorbidity modified this association.     

Influence of fast-track programs on patient-reported outcomes in total hip and knee replacement (THR/TKR) at Swedish hospitals 2011–2015: an observational study including 51,169 THR and 8,393 TKR operations

Background and purpose — Fast-track care programs have been broadly introduced at Swedish hospitals in elective total hip and knee replacement (THR/TKR). We studied the influence of fast-track programs on patient-reported outcomes (PROs) 1 year after surgery, by exploring outcome measures registered in the Swedish arthroplasty registers.Patients and methods — Data were obtained from the Swedish Knee and Hip Arthroplasty Registers and included TKR and THR operations 2011–2015 on patients with osteoarthritis. Based on questionnaires concerning the clinical pathway and care programs at Swedish hospitals, the patients were divided in 2 groups depending on whether they had been operated in a fast-track program or not. PROs of the fast-track group were compared with not fast-track using regression analysis. EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS were analyzed for both THR and TKR operations. The PROMs for TKR also included KOOS.Results — The differences of EQ-5D, EQ VAS, Pain VAS, and Satisfaction VAS 1 year after surgery were small but all in favor of fast-track for both THR and TKR, also in subscales of KOOS for TKR except KOOS QoL. However, the effect sizes as measured by Cohens’ d formula were < 0.2 for all PROs, in both THR and TKR.Interpretation — Our results indicate that the fast-track programs may be at least as good as conventional care from the perspective of PROs 1-year postoperatively.

Fast-track care programs in elective total hip and knee replacement (THR and TKR) were introduced in Europe at the beginning of the 2000s (Husted et al. 2006, Pilot et al. 2006). Using evidence-based methods in preparation and perioperative care aims to reduce surgical and psychological stress and accelerate recovery after surgery (Kehlet et al. 2008). The care concept has been spread worldwide (Antrobus and Bryson 2011, Christelis et al. 2015, Stowers et al. 2016), resulting in short perioperative hospital stay, and is considered to be safe and well tolerated by patients (Machin et al. 2013, Zhu et al. 2017, Deng et al. 2019, Wainwright and Kehlet 2019). During the last few years an increasing number of ambulatory arthroplasties have been performed as outpatients with maintained safety and short-term outcome (Goyal et al. 2017), Gromov et al. 2019, Coenders et al. 2020). The patients’ experiences and degree of satisfaction have been explored in qualitative studies (Specht et al. 2016, Strickland et al. 2018) and by self-made questionnaires concerning satisfaction rating of the care (Husted and Holm 2006, Specht et al. 2015, Winther et al. 2015).Patient reported outcomes (PROs) after THR and TKR with fast-track programs have been reported using both generic and disease-specific questionnaires (Larsen et al. 2010, 2012, Winther et al. 2015). The follow-up periods have been of different length and only a few of them had a control group with standard care (Larsen et al. 2008, Machin et al. 2013). The PROs with fast-track programs have been compared with PROs from an age- and sex-matched population (Larsen et al. 2010, 2012), and the THR patients but not TKR patients reached the population level after 12 months. In a study from Norway the PROs after 12 months were lower than the matched population level but similar to register-based average gain in general health (EQ-5D) in THR patients (Winther et al. 2015). Brock et al. (2017) studied the length of stay and its impact on WOMAC and SF-36 1 year after surgery. They found a slight improvement of SF-36 associated with shorter LOS but no significant influence on WOMAC. The question remains whether PROs 1 year after THR and TKR are better with fast-track or not compared with conventional care programs.In Sweden, fast-track programs have been broadly implemented for hip and knee replacements during 2011–2015. We studied the influence of the fast-track programs on PROs in elective THR and TKR 1 year after surgery by exploring the PROs registered in the Swedish hip and knee arthroplasty registers (SHAR and SKAR).     

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi

Background and purpose — Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi.Patients and methods — Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury.Results — Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02).Interpretation — Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

The gold standard treatment for femoral shaft fractures is intramedullary nailing (IMN), with low complication rates ranging from 1.2% to 5% for postoperative infection (Brumback et al. 2006, Young et al. 2013a, Salawu et al. 2017) and high union rates ranging from 72% to 100% (Ricci et al. 2001, El Moumni et al. 2009, Young et al. 2013b). However, nonoperative treatment using skeletal traction (ST) for at least 6 weeks remains the mainstay treatment for these fractures in low-resource settings (Hollis et al. 2015, Kramer et al. 2016). Nonoperative treatment is associated with increased risk of both medical and surgical complications, reported as high as 55% in some studies (Bucholz and Jones 1991, Doorgakant and Mkandawire 2012, Kramer et al. 2016, Parkes et al. 2017).In Malawi, femoral shaft fractures are most commonly treated by ST. IMN, when performed, is done using the SIGN IM nail, which is donated by SIGN Fracture Care International (Richland, WA, USA) (Shah et al. 2004). Most studies comparing IMN with ST in LICs used conventional measures such as fracture union, complications, and range of motion (Swai 2005, Kamau et al. 2014, Parkes et al. 2017). No prior study has measured quality of life or function using a validated patient-reported outcome instrument to compare ST and IMN in any context.This study compared the quality of life and functional status of patients with femoral shaft fractures treated with either ST or IMN in Malawi.     

14-year hip survivorship after periacetabular osteotomy: a follow-up study on 1,385 hips

Background and purpose — Few studies have evaluated the long- and mid-term outcomes after minimally invasive periacetabular osteotomy (PAO). We investigated: (1) the long-term hip survival rate after PAO; (2) the risk of complications and additional surgery after PAO; and (3) the hip function at different follow-up points.Patients and methods — We reviewed 1,385 hips (1,126 patients) who underwent PAO between January 2004 and December 2017. Through inquiry to the Danish National Patient Registry we identified conversions to total hip arthroplasty (THA) and complications after PAO. We evaluated the Hip disability and Osteoarthritis Outcome Score (HOOS) obtained preoperatively, and at 6 months, 2-, 5-, and 10-years’ follow-up.Results — 73 of the 1,385 hips were converted to THA. The overall Kaplan–Meier hip survival rate was 80% (95% CI 68–88) at 14 years with a mean follow-up of 5 years (0.03–14). 1.1% of the hips had a complication requiring surgical intervention. The most common additional surgery was removal of screws (13%) and 11% received a hip arthroscopy. At the 2-year follow-up, HOOS pain improved by a mean of 26 points (CI 24–28) and a HOOS pain score > 50 was observed in 86%.Interpretation — PAO preserved 4 of 5 hips at 14 years, with higher age leading to lower survivorship. The PAO technique was shown to be safe; 1.1% of patients had a complication that demanded surgical intervention. The majority of the patients with preserved hips have no or low pain. The operation is effective with a good clinical outcome.

Periacetabular osteotomy (PAO) is the most common surgical procedure to treat symptomatic hip dysplasia (Ganz et al. 1988, Clohisy et al. 2009). Previous studies have reported a 10-year hip survivorship of 78–95% in patients undergoing PAO. These studies, however, only include a small number of hips and surgical procedures performed during the surgical learning curve (Steppacher et al. 2008, Matheney et al. 2009, Hartig-Andreasen et al. 2012, Albers et al. 2013, Lerch et al. 2017, Ziran et al. 2018).In addition to hip survivorship, several studies have investigated the risk of complications following PAO. It has been estimated that early serious complications occurred in 6–37% of patients (Clohisy et al. 2009). Delayed complication rates suggested that 9% of patients had major complications requiring surgical or arthroscopic intervention, including nonunion, hematoma/deep infection, revision PAO, heterotopic ossification, intraoperative fractures, osteotomy, or sciatic nerve damage (Wells et al. 2018b). To our knowledge, only a few studies have evaluated the long-term complications after PAO (Wells et al. 2018b).Moreover, conversion to total hip arthroplasty (THA) may not be sufficient to describe the outcome after PAO, since patients may not want a THA or surgeons may not recommend it. Patient-reported outcomes (PRO) can therefore supplement the evaluation of the outcome after PAO. Previous studies have used different PROs to identify a failure after PAO, including the Merle d’Aubigné–Postel score < 15 or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) ≥ 10 (Matheney et al. 2009, Hartig-Andreasen et al. 2012, Albers et al. 2013, Lerch et al. 2017, Wells et al. 2018a). In this study, we used the Hip disability and Osteoarthritis Outcome Score (HOOS).This study determines (1) long-term hip survival rate after PAO; (2) risk of complications after PAO; (3) hip function using HOOS at different follow-up points.     

No association between blood count levels and whole-blood cobalt and chromium levels in 1,900 patients with metal-on-metal hip arthroplasty

Background and purpose — The accelerated wear of poorly functioning metal-on-metal (MoM) hip implants may cause elevated whole-blood cobalt (Co) and chromium (Cr) levels. Hematological and endocrinological changes have been described as the most sensitive adverse effects due to Co exposure. We studied whether there is an association between whole-blood Co/Cr levels and leukocyte, hemoglobin, or platelet levels.Patients and methods — We analyzed whole-blood Co and Cr values and complete blood counts (including leukocytes, hemoglobin, platelets) from 1,900 patients with MoM hips. The mean age at the time of whole-blood metal ion measurements was 67 years (SD 10). The mean time from primary surgery to whole-blood metal ion measurement was 8.2 years (SD 3.0). The mean interval between postoperative blood counts and metal ion measurements was 0.2 months (SD 2.7).Results — The median Co value was 1.9 µg/L (0.2–225), Cr 1.6 µg/L (0.2–125), mean leukocyte count 6.7 × 10⁹/L (SD 1.9), hemoglobin value 143 g/L (SD 13), and platelet count 277 × 10⁹/L (SD 70). We did not observe clinically significant correlations between whole-blood Co/Cr and leukocyte, hemoglobin, or platelet counts.Interpretation — Elevated whole-blood Co and Cr values are unlikely to explain abnormal blood counts in patients with MoM hips and the reason for possible abnormal blood counts should be sought elsewhere.

The abnormal wear of poorly functioning MoM implants may cause elevated whole-blood cobalt (Co) and chromium (Cr) levels (Brodner et al. 2003, Cheung et al. 2016). Soft-tissue reactions termed “pseudotumors” related to poorly functioning MoM hip replacements have been widely described (Boardman et al. 2006, Gruber et al. 2007, Pandit et al. 2008). The use of MoM implants has dramatically decreased but due to their previous popularity there are still a large number of patients with MoM hip replacements under follow-up (Silverman et al. 2016).Even though local reactions have been the most discussed, systemic reactions in patients with high-wearing hip implants have been described. Cardiomyopathy, polyneuropathy, hypothyreosis, and polycythemia have been described in some patients with MoM hip implants and in patients with fractured ceramic-on-ceramic implant revised to metal-on-polyethylene, resulting in abrasive wear of the CoCr head by ceramic fragments (Cheung et al. 2016). Systemic adverse events have been linked mostly to Co, and hematological and thyroid effects have been described as the most sensitive responses to Co in humans (Tvermoes et al. 2014). A case report described polycythemia with hemoglobin 190 g/L due to massive abrasive CoCr head wear when a ceramic-on-ceramic implant had been revised to metal-on-polyethylene after fracture of the ceramic liner (Gilbert et al. 2013). Several studies have suggested that blood lymphocyte counts may be affected by implant metals from MoM hip replacements (Hart et al. 2009, Hailer et al. 2011, Penny et al. 2013, Chen et al. 2014, Briggs et al. 2015, Markel et al. 2018). Although thrombocytopenia has not been linked to implant metals, it has been reported that platelets adhere to and are activated by CoCr (Ollivier et al. 2017).Complete blood count including leukocyte count, hemoglobin, and platelets is among the most used blood tests in the world (Horton et al. 2019) and 10–20% of the measurements include abnormal values (Tefferi et al. 2005). Due to wide media attention to MoM hip replacements, patients with MoM hips are sometimes worried whether their abnormal laboratory findings are related to their hip replacement. We sought to find out whether whole-blood metal ion levels are associated with blood count. Our hypothesis was that if Co or Cr affected leukocytes, hemoglobin, or platelets at concentrations noted in our study group, we would observe an upward or downward trend (depending on variable) when blood Co or Cr concentrations are approaching the highest values.     

Uncemented or cemented stems in first-time revision total hip replacement? An observational study of 867 patients including assessment of femoral bone defect size

Background and purpose — Uncemented stems are gradually replacing cemented stems in hip revision surgery. We compared the risk of re-revision between uncemented and cemented revision stems and assessed whether the different fixation methods are used in similar femoral bone defects.Patients and methods — 867 patients operated on with uncemented or cemented stems in first-time hip revision surgery due to aseptic loosening performed 2006–2016 were identified in the Swedish Hip Arthroplasty Register. Preoperative femoral bone defect size was assessed on radiographs of all patients. Cox regression models were fitted to estimate the adjusted risk of re-revision during different postoperative time periods. Re-revision of any component for any reason, and stem re-revision, as well as risk of cause-specific re-revision was estimated.Results — Most patients in both fixation groups had Paprosky class IIIA femoral bone defects prior to surgery, but there were more severe bone defects in the cemented group. The adjusted risk of re-revision of any component for any reason was higher in patients with uncemented compared with those with cemented revision stems during the first 3 years after index surgery (hazard ratio [HR] 4, 95% confidence interval [CI] 2–9). From the 4th year onward, the risk of re-revision of any component for any reason was similar (HR 0.5, CI 0.2–1.4). Uncemented revision stems conferred a higher risk of dislocation compared with cemented stems (HR 5, CI 1.2–23) during the first 3 years.Interpretation — Although not predominantly used in more complex femoral defects, uncemented revision stem fixation confers a slightly higher risk of re-revision during the first years, but this risk is attenuated after longer follow-up.

The increased use of primary total hip replacement (THR) has been followed by a steady rise in the frequency of revision surgery (Kurtz et al. 2007, Rajaee et al. 2018), and the use of uncemented revision stems is increasing in most countries (Swedish Hip Arthroplasty Register [SHAR] 2015). Some surgeons consider uncemented revision stems to be more appropriate in situations with extensive femoral bone loss, but others use long cemented revision stems, sometimes in conjunction with bone impaction grafting. Ultimately, the choice of fixation method in revision surgery is a matter not only of science and evidence, but also of taste and local tradition.Register-based studies indicate that uncemented revision stems may have inferior implant survival when compared with cemented stems, especially in the older population (Weiss et al. 2011, Tyson et al. 2019). However, these register studies lack information on femoral bone defect size, a factor that can affect the choice both of fixation method and of outcome in terms of re-revision rates (Paprosky et al. 1999, Pekkarinen et al. 2000, Della Valle and Paprosky 2004, Ten Have et al. 2012).Some smaller observational studies address bone defect size: in 86 patients with comparable femoral bone defects the choice of fixation has no certain influence on implant survival (Iorio et al. 2008), whereas uncemented revision stems conferred inferior implant survival compared with cemented revision stems in 209 patients with comparable femoral bone defects (Hernigou et al. 2015). However, both studies included different reasons for revision surgery, and the second study included both first-time and multiply revised patients.Taken together, the available evidence on the optimal mode of revision stem fixation is hampered by small cohort sizes and lack of control groups (Berry et al. 1995, Iorio et al. 2008, Ornstein et al. 2009, Lakstein et al. 2010, Hernigou et al. 2015, Stigbrand and Ullmark 2017), there is a lack of information on indications underlying revision surgery (Iorio et al. 2008, Weiss et al. 2011, Hernigou et al. 2015), and, most importantly, in large register studies there is no information on the femoral bone defect sizes present at revision surgery (Weiss et al. 2011, Tyson et al. 2019). Our primary aim was therefore to compare the risk of re-revision of any component for any reason between uncemented and cemented stems in hip revision surgery with adjustment for preoperative femoral bone defect size in a large cohort of patients. Our secondary aims were to investigate whether uncemented and cemented revision stems were used in patients with different bone defect sizes, and to assess if the risk of stem re-revision, as well as risk of re-revision of any component due to aseptic loosening, dislocation, fracture, deep infection, and other reasons differed between the 2 fixation techniques.     

Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity,hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls

Background and purpose — Associations between obesity and slipped capital femoral epiphysis (SCFE) during adolescence are described; however, few studies report on the lifetime risk of obesity in patients with SCFE. In addition, with the obesity epidemic in children and adolescents, an increasing incidence of SCFE might be expected. An association of SCFE with hypothyroidism seems ambiguous, and the association between SCFE and depression and all-cause mortality has not yet been evaluated. This study investigates the associations of SCFE with obesity, hypothyroidism, depression, and mortality, and putative changes in the yearly incidence of SCFE.Patients and methods — 2,564 patients diagnosed with SCFE at age 5–16 diagnosed between 1964 and 2011 were identified in the Swedish Patient Register. These were matched for age, sex, and residency with unexposed control individuals. Cox regression models were fitted to estimate the risk of obesity, hypothyroidism, depression, and death, in exposed compared with unexposed individuals.Results — The risk of obesity (HR 9, 95% CI 7–11) and hypothyroidism (HR 3, CI 2–4) was higher in SCFE patients compared with controls. There was no increase in the risk of developing depression (HR 1, CI 1–1.3) in SCFE patients. In contrast, all-cause mortality was higher in SCFE patients than in controls (HR 2, CI 1–2). The incidence of SCFE did not increase over the past decades.Interpretation — Patients with SCFE have a higher lifetime risk of obesity and hypothyroidism and a higher risk of all-cause mortality compared with individuals without SCFE. These findings highlight the lifetime comorbidity burden of patients who develop SCFE in childhood, and increased surveillance of patients with a history of SCFE may be warranted. The incidence of SCFE did not increase over the last decades despite increasing obesity rates.

Slipped capital femoral epiphysis (SCFE) occurs commonly in overweight children and adolescents. The etiology of the disease is still unknown but several studies have concluded that overweight and obesity are catalyzing factors, either by overloading the growth plate (Fishkin et al. 2006) or as an endocrine condition diminishing the stability of the growth plate. The latter would explain the age-dependent relationship between obesity and SCFE onset, where obese children are found to suffer from SCFE at a younger age compared with children of age- and length-adequate weight (Perry et al. 2018). Wensaas et al. (2011) investigated the long-term outcome of 66 patients with a history of SCFE and found that one-third were overweight or obese in adulthood. However, the risk of developing obesity in SCFE patients, not only in childhood but during later life, is still unknown.In contrast, presuming obesity as a causal factor, one would expect higher incidences of SCFE due to epidemic obesity rates in children and adolescents (Murray and Wilson 2008). However, comparisons of incidence rates are often difficult because the calculations are based on different age groups and changes in incidence rates over the past decades have not yet been reported.Inconsistent findings concerning the association between SCFE and hypothyroidism have emerged. Some authors found no association between SCFE and hypothyroidism (Brenkel et al. 1988), whereas others found an association of the 2 diseases (Kadowaki et al. 2017). Congenital hypothyroidism is part of the screening program of newborns in Sweden (National Board of Health and Welfare 2018) but acquired hypothyroidism is often underdiagnosed in children and adolescents (Ghaemi et al. 2015). To my knowledge, there is no study investigating the lifetime risk of hypothyroidism in patients with a history of SCFE.Studies focusing on the long-term outcome after SCFE (Wensaas et al. 2011, Castaneda et al. 2013, Wiemann and Herrera-Soto 2013, de Poorter et al. 2016) attest that SCFE is not only a childhood hip disease: In some patients SCFE transforms into a chronic disease by creating hip joint impingement (Lerch et al. 2019) or premature osteoarthritis, or both (Goodman et al. 1997). It is known that patients with chronic diseases are at greater risk of developing depression (Moussavi et al. 2007, Podeszwa et al. 2015) and die earlier (Ng et al. 2007, Hailer and Nilsson 2014) compared with the general population.Thus, the lifetime burden of obesity, hypothyroidism, and depression in patients exposed to SCFE remains unclear and leads to the following questions: (1) Do patients with SCFE have an increased lifetime risk of obesity and hypothyroidism? (2) Has the average incidence of SCFE in Sweden changed over the past few decades? (3) Is SCFE associated with a higher risk of depression and a higher risk of all-cause mortality?     

Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work,sports, and leisure activities

Background and purpose — Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities.Patients and methods — A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned.Results — The questionnaire was completed by 175 patients, age 66 years (range 38–84), 57% female, BMI 29 (IQR 25–33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3—intra-articular injection—was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best.Interpretation — Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

Worldwide guidelines for managing osteoarthritis (OA) of the hip and knee advise extensive non-surgical treatment prior to surgery (Zhang et al. 2010, Smink et al. 2011, McAlindon et al. 2014). Non-surgical treatment is cost-effective and may lower the rapidly increasing OA-related healthcare expenditure by delaying or even replacing surgery (Berwick and Hackbarth 2012).The global Choosing Wisely initiative aims to optimize healthcare usage and costs by advocating the use of proven but underused healthcare modalities, including preventive care (Berwick and Hackbarth 2012, Bernstein 2015). Regarding hip and knee OA, studies have found underuse of non-surgical treatments (Snijders et al. 2011, Hofstede et al. 2015). For example, 1 study showed that 81% of hip and knee OA patients did not receive all recommended non-surgical treatments (Snijders et al. 2011). In the Netherlands, a Stepped Care Strategy (SCS) was developed to stimulate the use of non-surgical treatment before hip and knee replacement (Smink et al. 2011). Moreover, providing adequate non-surgical treatment before hip and knee replacement was recommended by the Dutch Orthopedic Association for their Choosing Wisely Campaign (NOV 2015). Yet, the actual utilization of non-surgical treatment in hip and knee OA patients prior to arthroplasty in the Netherlands is described only by a cohort study from 2013 (Hofstede et al. 2015). Furthermore, no previous study has simultaneously assessed patient satisfaction with non-surgical treatments regarding their effect on symptoms like pain and swelling, and participation as in daily life and work. This is of importance given the increasing number of hip and knee OA patients who want to eliminate their pain and also wish to remain active in daily life, work, and sport/leisure (Kurtz et al. 2009, Otten et al. 2010, Culliford et al. 2015, Witjes et al. 2017). Given the impact of surgery on work participation, the effect of non-surgical treatment on work participation is also of interest (Kuijer et al. 2016, Stigmar et al. 2017).Therefore, the main aim was to assess preoperative non-surgical treatment by hip and knee OA patients referred for arthroplasty in 2018, as well as compared with 2013, and their satisfaction regarding alleviation of symptoms and performing activities of daily living (ADL), work, and sports/leisure activities.     

Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures

Background and purpose — Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population.Patients and methods — 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1–6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds.Results — Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7–15 years was ≥ 3:100,000.Interpretation — Displaced fractures of the medial humeral epicondyle in children heal well with 3–4 weeks’ immobilization. Open reduction and screw fixation does not improve outcome.

Fractures of the medial humeral epicondyle have been reported to account for 12–20% of all pediatric elbow fractures, but the incidence is not known. Elbow dislocation is associated with 30–50% of these fractures (Gottschalk et al. 2012), with an incarceration rate of the fracture fragment into the elbow joint of 5–18%. Ulnar nerve lesions are registered in 10–16% of cases (Louhaem et al. 2010).Nonoperative treatment is advised in minimally displaced (< 2 mm) fractures of the medial humeral epicondyle, whereas surgery is recommended for fractures incarcerated in the elbow joint as well as for fractures that are either grossly unstable or where the ulnar nerve is entrapped (Smith 1950, Blount 1955, Maylahn and Fahey 1958, Bede et al. 1975, Gottschalk et al. 2012, Tarollo et al. 2015). Significant controversy concerning the treatment of displaced (3–15 mm) fractures exists, with some surgeons advocating early mobilization, some immobilization, and some internal fixation (Lee et al. 2005, Hughes et al. 2019, Pezzutti et al. 2020). It has also been suggested that competitive athletes or fractures occurring in combination with elbow dislocation should be treated surgically with a lower threshold than in children without sporting activities (Baety and Kasser 2014).The reported outcome of nonoperative and operative treatment in displaced fractures of the medial humeral epicondyle in terms of elbow function and complications has been similar (Farsetti et al. 2001, Biggers et al. 2015, Axibal et al. 2019).We compared subjective and objective outcomes and calculated the incidence of medial humeral epicondyle fractures in children treated either with immobilization or with open reduction and internal fixation (ORIF).     

Modified Harrington’s procedure for periacetabular metastases in 89 cases: a reliable method for cancer patients with good functional outcome,especially with long expected survival

Background and purpose — The pelvis is the 3rd most common site of skeletal metastases. In some cases, periacetabular lesions require palliative surgical management. We investigated functional outcome, complications, and implant and patient survival after a modified Harrington’s procedure.Patients and methods — This retrospective cohort study included 89 cases of surgically treated periacetabular metastases. All patients were treated with the modified Harrington’s procedure including a restoration ring. Lesions were classified according to Harrington. Functional outcome was assessed by Harris Hip Score (HHS) and Oxford Hip Score (OHS). Postoperative complications, and implant and patient survival are reported.Results — The overall postoperative functional outcome was good to fair (OHS 37 and HHS 76). Sex, age, survival > 6 and 12 months, and diagnosis of the primary tumor affected functional outcome. Overall implant survival was 96% (95% Cl 88–100) at 1 year, 2 years, and 5 years; only 1 acetabular implant required revision. Median patient survival was 8 months (0–125). 10/89 patients had postoperative complications: 6 major complications, leading to revision surgery, and 4 minor complications.Interpretation — Our modified Harrington’s procedure with a restoration ring to achieve stable fixation, constrained acetabular cup to prevent dislocation, and antegrade iliac screws to prevent cranial protrusion is a reliable reconstruction for periacetabular metastases and results in a good functional outcome in patients with prolonged survival. A standardized procedure and low complication rate encourage the use of this method for all Harrington class defects.

The pelvis is the 3rd most common site for surgically treated skeletal metastases after the femur and humerus (Ratasvuori et al. 2013).In deciding whether and how to operate on periacetabular lesions, the estimated patient survival and size of the skeletal lesion should be considered. Expected survival is dependent on the type of primary tumor and metastatic burden. The mean survival of pathological fractures in the pelvic area is usually less than 2 years (Hansen et al. 2004, Ratasvuori et al. 2014).Periacetabular defects can be reconstructed in several ways depending on the extent. Harrington’s classification separates cases as follows: class I, the acetabular lateral cortices and superior and medial walls are intact; class II, the medial wall is deficient; class III, the lateral cortices, medial wall, and superior wall are all deficient; and class IV, there is wide destruction all the way to the wing of the ilium (Harrington 1981). Harrington also designed a method for reconstruction in cases in which the periacetabular bone presents extensive loss, as in classes III and IV. In this conventional procedure, antegrade pins (from the wing of the ilium to the acetabular dome) or retrograde pins (from the acetabular dome into the wing of the ilium and into the sacroiliac joint) are used. Other methods are also available for the reconstruction, such as filling metastatic cavities with bone cement (cementoplasty), acetabular cages, custom-made pelvic endoprostheses, and the “ice-cream cone” periacetabular prosthesis (Walker 1993, Harrington 1995, Fisher et al. 2011).The original Harrington’s procedure is rarely used any more, whereas some studies have other procedures, usually less invasive, e.g., no pins in the iliac crest (Tsagozis et al. 2015), using short screws or pins (Bernthal et al. 2015, Tsagozis et al. 2015), and not performing arthroplasty (Charles et al. 2017). Sample sizes in publications reporting conventional and modified Harrington’s technique are small, ranging from 19 to 51 patients (Harrington 1981, Nilsson et al. 2000, Tillman et al. 2008, Shahid et al. 2014, Charles et al. 2017), and the publications reporting functional outcomes are few (Nilsson et al. 2000, Charles et al. 2017).The aim of this study was to report the functional outcome, post-operative implant survival, including complications, and patient survival after modified Harrington’s procedure.     

Ankle fracture classification using deep learning: automating detailed AO Foundation/Orthopedic Trauma Association (AO/OTA) 2018 malleolar fracture identification reaches a high degree of correct classification

Background and purpose — Classification of ankle fractures is crucial for guiding treatment but advanced classifications such as the AO Foundation/Orthopedic Trauma Association (AO/OTA) are often too complex for human observers to learn and use. We have therefore investigated whether an automated algorithm that uses deep learning can learn to classify radiographs according to the new AO/OTA 2018 standards.Method — We trained a neural network based on the ResNet architecture on 4,941 radiographic ankle examinations. All images were classified according to the AO/OTA 2018 classification. A senior orthopedic surgeon (MG) then re-evaluated all images with fractures. We evaluated the network against a test set of 400 patients reviewed by 2 expert observers (MG, AS) independently.Results — In the training dataset, about half of the examinations contained fractures. The majority of the fractures were malleolar, of which the type B injuries represented almost 60% of the cases. Average area under the area under the receiver operating characteristic curve (AUC) was 0.90 (95% CI 0.82–0.94) for correctly classifying AO/OTA class where the most common major fractures, the malleolar type B fractures, reached an AUC of 0.93 (CI 0.90–0.95). The poorest performing type was malleolar A fractures, which included avulsions of the fibular tip.Interpretation — We found that a neural network could attain the required performance to aid with a detailed ankle fracture classification. This approach could be scaled up to other body parts. As the type of fracture is an important part of orthopedic decision-making, this is an important step toward computer-assisted decision-making.

Ankle fractures are recognized among the most common fractures, with peak incidence between 15 and 29 years (67 per 100,000 person-years) and elderly women ≥ 60 years (174 per 100,000 person-years) (Westerman and Porter 2007, Thur et al. 2012). Efforts to classify ankle fractures in clinically relevant entities have a long history, ending in 3 classic systems, i.e., the Lauge-Hansen (Hansen 1942), Danis–Weber, and the AO/OTA classifications (Association Committee for Coding and Classification 1996; Budny and Young 2008), where the Danis–Weber with its A, B, and C classes is probably the most used in everyday practice.The most recent update for the AO/OTA classification system was published in 2018 (Meinberg et al. 2018). The AO/OTA system contains classifications for the entire body. The ankle is divided into (1) malleolar, (2) distal tibia, and (3) fibular fractures. For malleolar fractures, the subcategories correspond to the Danis–Weber ABC classification (Hughes et al. 1979) with the addition of a suffix of 2 digits (range 1–3), e.g., the common intra-syndesmotic B-injury without widening of the mortise corresponds to the B1.1 class. The numbers correspond roughly to the severity of each fracture.The complexity of this classification makes it difficult to learn and apply, limiting inter-observer reliability and reproducibility (Fonseca et al. 2017). This has hindered its use in an everyday clinical setting, suggesting the need for better aid during the classification.During recent years, the resurgence of neural networks, a form of artificial intelligence (AI), has proven highly successful for image classification. In some medical image classification applications neural networks attain (Olczak et al. 2017, Kim and MacKinnon 2018, Gan et al. 2019), and surpass, human expert performance (Esteva et al. 2017, Lee et al. 2017, Chung et al. 2018, Urakawa et al. 2019). Machine learning and neural networks are also becoming more commonplace research tools in orthopedics. They hold great potential, as the diagnostic underpinning and intervention decision relies heavily on medical imaging (Cabitza et al. 2018). The strength of these learning algorithms is their ability to review a vast number of examinations and examples, and the speed and consistency with which they can review each examination and at the same time remember thousands of categories without issue.We therefore hypothesized that a neural network can learn to classify ankle fractures according to the AO/OTA 2018 classification from radiographs.