Treatment of hip fracture in Finland and Sweden. Prospective comparison of 788 cases in three hospitals.

A prospective population-based study of hip fracture treatment was performed during 1989 in the regional hospitals of Oulu (Finland) and Sundsvall and Lund (Sweden). For cervical fractures hemiarthroplasty was preferred in Oulu and osteosynthesis in Sundsvall and Lund. For trochanteric fractures screw-plate was preferred in Oulu and Lund and Ender-nailing in Sundsvall. A shorter mean time at the orthopedic department in Oulu (13 days) was compensated by a lower (14 percent) fraction of patients directly discharged to own home. A somewhat longer mean orthopedic hospitalization time in Sundsvall (19 days) and Lund (17 days) was combined with a higher discharge to own home (49 percent and 35 percent). Prospective multicenter comparisons of treatment combinations (both operation and rehabilitation) permit identification of programs that are optimal for both patient and society.     

Hip fractures in Hungary and Sweden - differences in treatment and rehabilitation

Data of 1,337 consecutive hip fracture patients were registered during 1 year within a prospective comparative multicenter study comparing osteosynthesis techniques and rehabilitation results in Budapest, Hungary, in Sundsvall, northern Sweden, and in Lund, southern Sweden. In Budapest the mean age was 4-5 years lower than in Sweden, and more patients lived in their own home (91% versus 70% and 62%). Less intracapsular (41% versus 54% and 54%) and more trochanteric fractures (52% versus 40% and 35%) were observed in Budapest. Many more Hungarian patients returned home (68% versus 54% and 33%); however, their mortality rate 4 months later significantly exceeded that of the Swedish centres (24% versus 15% and 13%), and more had severe pain in the operated hip (27% versus 17% and 15%). Four months after double nail osteosynthesis of displaced cervical fractures, more patients (28%) had severe hip pain than after hemiarthroplasty (16%) in Budapest as compared to Lund or Sundsvall (19% and 22%). Mortality rate after 4 months following hemiarthroplasty and nailing (36% and 20%) was significantly higher than in the Swedish centres (14% and 11%).     

Quality of life after primary hemiarthroplasty for femoral neck fracture: 6-year follow-up of 185 patients

Totally, 185 patients with a mean age of 80 years treated by Austin-Moore cementless hemiarthroplasty for an acute femoral neck fracture were compared with age- and sex-matched nonfracture controls. There were 22 early complications, notably 7 percent dislocation and 4 percent deep infection. Later on, two acetabular protrusions and four loosenings of the prosthesis requiring admission were recorded. Mortality after the fracture was 12 percent above the control level at 3 months, 19 percent at 12 months, and 21 percent at 18 months. The 5-year mortality was about 60 percent in both patients and controls. The average loss of life in the fracture group compared with the control group was 425 days. After a mean follow-up period of 6 years, 24 of the 65 patients still alive and the 49 of the 60 controls were living in their own homes; and 28 of the patients were institutionalized in a hospital unit for chronic care. Half of the patients and most of the controls were able to move about independently.

We concluded that Austin-Moore hemiarthroplasty is associated with serious complications that prevent social rehabilitation and function to reach acceptable levels.     

Early prediction of functional outcome after stroke

Objectives: (I) To obtain biomechanical parameters and assessment scores applied at a very early stage after stroke that predict best the functional outcome after rehabilitation. (II) To evaluate the predictive value of changes (i.e. increase or decrease) of these parameters during the first week in relation to the predictive value of their absolute scores.

Design: Prospective outcome study.

Subjects: Forty-one stroke patients, admitted to the stroke unit within 24 hours.

Main outcome measures: Barthel Index, Rivermead Motor Assessment, Motor Club Assessment and Functional movement activities, NIH-Stroke scale (NIH-SS), Grip strength.

Results: Parameters assessed within the first hours after stroke correlated only weakly with the outcome. The best model predicting functional outcome and independence in activities of daily living of stroke patients after 6 months was that including NIH-SS, grip strength, age and previous stroke explaining 79% of the variance. These parameters assessed on day 7 post-stroke are more predictive than the difference between stroke onset and day 7 post-stroke.

Conclusion: Parameters for predicting outcome should not be assessed before day 7 post-stroke.     

Nailing of femoral neck fracture: Clinical and sociologic 5-year follow-up of 510 consecutive hips

In a retrospective population-based study, 510 consecutive cervical hip fractures treated by internal fixation with a spring-loaded four-flanged nail, early weight bearing, and social rehabilitation were examined at 5 years after primary nailing. Six (1.6 percent) deep infections occurred. After a new trauma, seven fractures through the nail entrance were seen. Mortality at 2 years was 32 percent and at 5 years 53 percent. With a program for active rehabilitation, 80 percent of the survivors coming from independent living returned to this and remained there.

The frequency of reoperations in patients below age 70 years was twice as high as in those over 70. Secondary arthroplasty was performed in 6 percent of the 129 undisplaced fractures and in 25 percent of the 381 displaced fractures. Totally, 67 percent of the fractures had no secondary procedure, not even nail extraction.     

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.     

Functional outcome at 1 vs. 2 years after severe traumatic brain injury

Purpose: The aim of the study was to evaluate the outcome of patients with severe traumatic brain injury (STBI) after 12 and 24 months (Glasgow Coma Scale GCS ≤ 8 points for at least 24 hours).

Methods: A total of 51 patients underwent a multidisciplinary early rehabilitation treatment until they were discharged from hospital and local ambulatory care was deemed sufficient. The follow-up examination took place 12 and 24 months after the STBI.

Results: Data revealed a high level of independence in activities of daily living (mean Barthel Index after 1 year 92.7 points, after 2 years 93.7 points). After 1 and 2 years, 74.5% and 80.4% of the patients, respectively, were completely independent of need for care. Nevertheless, more than half of the patients had sensorimotor, behavioural, speech, visual and/or auditory disturbances. Return to work rates improved between 1-2 years after trauma, as evidenced by the rate of patients being back to full time work at 1 year (n = 14, 28%) and 2 years (n = 20, 40%) post-STBI; although none of these changes reached statistical significance.

Conclusion: In summary, there are still changes in both impairment and disability related areas between 1-2 years post-STBI, but the degree of improvement is variable depending on the area being considered. Clinicians should remain aware of the fact that modulation of impairment and disability appear to continue well beyond 1 year post-STBI, which may impact on decisions regarding the provision and intensity of further rehabilitation efforts.     

Introduction of total hip arthroplasty in Lithuania: results from the first 10 years

Background Hip replacement as a routine procedure was introduced in Lithuania in 1991. At Klaipeda Hospital, one of the 2 hospitals at which this was begun, the arthroplasties were followed prospectively from the start. This study concerns the 10-year results from a country with no previous experience of hip replacement. The results are compared with those from a hospital with considerable experience of total hip replacement.

Methods We compared the revision rate for the first 658 primary ScanHip arthroplasties inserted at Klaipeda to that for the first 939 ScanHip primary arthroplasties inserted at Lund University Hospital, Sweden. Only patients with osteoarthritis were included, and the endpoint was revision for aseptic loosening with exchange of one or both components.

Results We found that patients operated at Klaipeda Hospital had a significantly higher risk of revision (12%) than those operated in Lund (6%).

Interpretation Although we could not identify any specific reason for the Swedish results being better than the Lithuanian results, it is probable that previous surgical inexperience of hip replacement in Lithuania played a role. We believe that the findings will stimulate surgeons in Lithuania to analyze their failures and improve the results.     

Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury

Primary objective: The aim of this study was to assess the effect of Botulinum toxin A in the management of spastic equinus resulting from traumatic brain injury.

Research design: A before-after intervention design was used without controls.

Methods and procedures: Subjects were seven patients suffering from traumatic brain injury of average duration 14 (4-38) months as a result of motor vehicle trauma, who had spastic equinus interfering with gait.

Experimental intervention: The patients were treated with injections of Botulinum toxin A into the spastic calf muscles: gastrocnemius, soleus and tibialis posterior. Assessments were made pre-injection and at 2 weeks and 3 months post-injection.

Main outcome and results: At the end of the 3-month period, all patients showed a significant improvement in gait velocity, cadence and stride length. Conclusions: The findings suggest that Botulinum toxin A may be useful in the management of spastic equinus following traumatic brain injury.     

Rehabilitation outcomes of cardiac and non-cardiac anoxic brain injury: a single institution experience

Objective: To compare the functional outcomes of patients with anoxic brain injury (ABI) due to cardiac and non-cardiac aetiologies.

Design: Retrospective chart review over 4 years.

Setting: Freestanding rehabilitation hospital.

Participants: Thirteen patients with cardiac ABI and 13 patients with non-cardiac ABI.

Intervention: Comprehensive, multi-disciplinary inpatient rehabilitation services.

Main outcome measures: Rehabilitation hospital length of stay (LOS) and cost; Functional Independence Measure (FIM) scores and its various sub-sets on admission and discharge; FIM efficiency and change; and discharge disposition.

Results: Patients with cardiac ABI were similar in gender and ethnicity when compared to patients with non-cardiac ABI but were older (average age 52 vs 42) with a higher percentage of cardiac patients married (77% vs 39%). No statistically significant differences were found between the two groups on all sub-sets of the FIM on admission and discharge as well as the different FIM efficiencies. However, there was a trend for the cardiac ABI patients to have a greater efficiency in improving mobility during rehabilitation when compared to non-cardiac ABI patients. The rehabilitation hospital LOS was ∼28 days less for patients with cardiac ABI (41.49 vs 69.84 days), but this difference was not statistically significant (p = 0.26). The mean rehabilitation cost for patients with cardiac ABI was ∼ $14 000 less than that for those with non-cardiac ABI ($44 181 vs $58 187). This difference was not statistically significant (p = 0.15). Cardiac ABI patients were more likely to be discharged directly to home from rehabilitation when compared to non-cardiac ABI patients (p = 0.06).

Conclusion: This pilot study demonstrates some differences in the recovery patterns of patients with ABI who had a cardiac aetiology and those who had non-cardiac aetiologies. While both groups experienced similar progress during rehabilitation, those with cardiac ABI made gains with a shorter LOS and less rehabilitation costs when compared to non-cardiac ABI patients. These data suggest a trend towards greater cost and length of stay for patients with ABI who had non-cardiac aetiologies.     

Knee arthrodesis with the Sheffield external ring fixator: fusion in 6 of 10 consecutive patients

Background Knee arthrodesis with external fixation (XF) is a possible salvage procedure for infected total knee arthroplasties (TKA). We report the outcome in 10 patients who underwent arthrodesis with the Sheffield Ring Fixator.

Patients and methods The patients had primary arthrosis in 8 cases; 2 cases were due to rheumatoid arthritis and sclerodermia. The mean time between the primary TKA and arthrodesis was 6 (0.5-14) years. The average age at arthrodesis was 69 years. The average follow-up period was 10 months.

Results Stable fusion was obtained in 6 patients after a mean XF time of 3.6 (2-4) months. 1 patient was referred to another hospital because of nonunion. This patient showed fusion with intramedullary nailing after 7 months. 3 nonunion patients required permanent bracing. 7 patients had pin tract infections. Infections healed in all patients.

Interpretation The Sheffield Ring Fixator gives an acceptable fusion rate for arthrodesis in the infected TKA, with limited complications.     

Traumatic brain injury and functional outcomes: does minority status matter?

Objectives: (1) to determine differences between minorities vs. non-minorities on demographic, injury and rehabilitation characteristics and functional outcomes at admission, discharge and 1-year post-injury and (2) to examine differences in functional outcome at 1-year post-injury among (African-Americans, Hispanics and Whites).

Design: Retrospective study.

Setting: Longitudinal data were extracted from the TBI Model Systems database.

Participants: 4929 individuals with moderate-to-severe TBI (3354 Whites vs. 1575 Minorities: 1207 African-Americans and 368 Hispanics) hospitalized between 1989-2004.

Main outcome measures: Functional outcomes at 1-year post-injury (Disability Rating Scale, Functional Independence Measure, Glasgow Outcome Scale-Extended and Community Integration Questionnaire).

Results: At discharge and 1-year post-injury, minorities had poorer functional outcomes compared with Caucasians on all measures. After controlling for sociodemographic, injury and functional characteristics at admission, Hispanics and African-Americans still showed worse functional outcomes at 1-year post-injury compared with Whites on the DRS, FIM and CIQ. There were no significant differences between African Americans and Hispanics.

Conclusions: Minorities had significantly reduced long-term functional outcome after rehabilitation relative to Whites. It is imperative that rehabilitation professionals' consider factors related to poorer long-term functional outcome and work to improve the quality of life of minorities with TBI.     

Parental alcohol misuse is a powerful predictor for the risk of traumatic brain injury in childhood

Background: Although the positive relationship between parental alcohol use and children's injuries is well established, it is not known whether parental alcohol misuse is a risk factor for traumatic brain injuries (TBIs) of their children and whether subjects with childhood TBI have hazardous drinking habits in adolescence.

Methods: The authors conducted a longitudinal cohort study at Oulu University Hospital. The cohort consisted of 12 058 subjects born in 1966, of which 207 had sustained TBI before the age of 14 years. Data on parental alcohol problems were obtained from the Finnish Hospital Discharge Register and the adolescents' drinking habits were analysed based on a postal inquiry at the age of 14 years.

Results: Parental alcohol misuse (RR 1.99, CI 1.19-3.33) and male gender (RR 1.53, CI 1.12-2.08) significantly predicted the risk of childhood TBI. Drinking to intoxication at the age of 14 was significantly associated with parental alcohol misuse (RR 1.62, CI 1.34-1.96), belonging to a one-parent family (RR 1.80, CI 1.61-2.02) and mild TBI (RR 1.67, CI 1.20-2.33).

Conclusions: It was observed that parental alcohol misuse is a major risk factor for TBI in children and drinking to intoxication is a common drinking pattern of adolescents who have sustained TBI in childhood.     

6 Weeks with the von Rosen splint is sufficient for treatment of neonatal hip instability

Background There is no concensus on the optimal treatment time for unstable hips in the newborn. We analyzed the efficiency of a treatment program that has been used for 10 years at our hospital, in which all unstable hips (subluxatable, Barlow-positive and Ortolani-positive) are treated with the von Rosen splint for 6 weeks.

Patients and methods Between 1988 and 1997, 32,171 children were born alive at the hospital. During this period 247 children had a clinically unstable hip diagnosed. 223 of the 247 children underwent a radiographic follow-up after 5-15 years.

Results 1 patient with bilateral instability and treated with a splint for 6 weeks showed a dislocated left hip at the radiographic examination at 8 months, which is part of the screening program, and needed operative treatment. 1 patient did not follow the treatment program and showed a dislocated hip at the age of 3. Another 4 patients required more treatment than the 6 weeks with the splint.

We found no dysplastic hips at the radiographic follow-up. There was no late dysplasia and there were no late dislocations in children born in Lund between 1988 and 1997 who were diagnosed at other Swedish centers that treat developmental dysplasia of the hip (DDH).

Interpretation We conclude that the present screening and 6-week treatment in a von Rosen splint prevent almost all cases of late dysplasia and late dislocation of the hip.     

Total condylar arthroplasty for gonarthrosis: A prospective 10-year study of 138 primary cases

The results of 138 consecutive primary Insall-Burstein arthroplasties with an average observation period of 10 (9-11) years were assessed. Mean age at surgery was 71 (30-81) years. The patients were evaluated clinically, using the Hospital for Special Surgery knee rating scale, and radiographically, according to the radiolucency score of the Knee Society.

At latest follow-up, the overall evaluation of the patients who completed the study was excellent or good in 86 percent, fair in 8 percent and poor in 6 percent. Residual functional pain was recorded in 12 percent of cases with prostheses in situ. An ability to walk more than 500 m was found in 62 percent. The median range of motion was 104°.

Arthrodesis was performed on 2 knees due to deep infection. There were 14 cases with substantial radiolucency around the prosthesis, but none of these patients had severe functional pain. The crude prosthetic survival rate was 98 percent. A correlation was found between the radiolucency score and both the total score and the intensity of the residual functional pain.     

Consumption of hospital resources for femoral neck fracture

In 1,673 patients with femoral neck fracture, the utilization of hospital and rehabilitation resources following primary operations and necessary reoperations was assessed in relation to type of treatment center and outcome of the fracture. All the patients were admitted from their homes to either orthopedic or general surgery departments, urban or rural/The fractures were treated by one of four osteosynthesis methods and followed for 6 years postoperatively.

About 30 per cent of the fractures developed healing complications. Patients treated in surgical departments utilized more acute and rehabilitation bed days than those treated in orthopedic departments. The patients stayed longer in city surgical departments than in rural surgical departments.

The Thornton osteosynthesis used by general surgical specialists resulted in 29 percent, mainly early complications, whereas the Rydell osteosynthesis used by orthopedic specialists had 24 percent, mainly late complications. This difference resulted in more than 40 percent higher consumption of bed days by the Thornton-nailed patient.

In sum, a fracture without complications consumed, on an average, 31 cost standardized bed days compared with 101 bed days for fracture with complications. Thus, every fracture with complications was SEK 112,000 more expensive than the complication-free one.     

Recovery from sports concussion in high school and collegiate athletes

Introduction: Neuropsychological testing is a valuable tool in concussion diagnosis and management. ImPACT, a computerized neuropsychological testing program, consists of eight cognitive tasks and a 21-item symptom inventory.

Method: ImPACT was used to examine the cognitive performance of 104 concussed athletes at baseline, 2, 7 and 14 days post-injury. Dependent measures included composite scores from the ImPACT computerized test battery, as well as a total symptom score from the Post-Concussion Symptom Scale.

Results: Differences between baseline and day 2 post-injury scores were observed for all ImPACT composites (Verbal memory-VERM, visual memory-VISM, processing speed-PROC and reaction time-RT) as well as in total symptom score (SX). At day 7, concussed athletes continued to perform significantly poorer on VERM, VISM, RT and SX. At day 14, only VERM scores were significantly different from baseline.

Conclusions: Cognitive performance deficits in concussed athletes may persist to 7 and even to 14 days in some cases. In addition to symptom status, the athlete's post-concussion cognitive functioning should be considered when making return-to-play decisions.     

Revision for aseptic loosening of uncemented cups in 4,352 primary total hip prostheses: A report from the Norwegian Arthroplasty Register

From September 1987 until January 1994 the Norwegian Arthroplasty Register recorded 5,021 primary total hip replacements performed with uncemented acetabular components. We compared the survival until revision for aseptic loosening of the cup, in the 11 commonest types (n 4,352).

The overall cumulative revision rate for the acetabular components was 3.2% after 5 years and 7.1 YO after 6 years, with large differences among the designs.

With the hydroxyapatite (HA)-coated cups and the hemispheric porous-coated cups, the failure rate was less than 0.1 YO. Of the unthreaded hemispheric porous-coated cups, Harris-Galante and Gemini (n 626), none had been revised, and of the HA-coated cups, Atoll and Tropic (n 1,943), only 1 had been revised.

For the threaded uncoated metal-backed cups, the results varied from no revisions of the PM cups (n 148) to a cumulative 6-year revision rate of 21 YO for the Ti-Fit (n 300). The all-polyethylene Endler cups (n 334) had a cumulative revision rate of 14%.

Women and patients with inflammatory arthritis had poorer results. However, the type and the design of the cups were of far greater importance for the results than patient-related factors.     

Wisconsin Card Sorting Test in chronic severe traumatic brain injury: factor structure and performance subgroups

Objective : The present study further investigated the factor structure of the WCST in traumatic brain injury and investigated the construct validity and relationships among scores through the use of cluster analysis.

Design : Participants were 68 survivors of chronic severe TBI, living at a residential brain injury rehabilitation facility.

Methods and procedures : Three sets of WCST scores were submitted to factor analysis; the regression factor scores based on the standard WCST were examined using cluster analysis.

Results : Factor analysis of the WCST raw scores replicated the three-factor solution which has been previously reported. When t -scores were analysed, two-to-four-factor solutions could be justified. The cluster analysis identified four groups representing: (1) impaired response maintenance; (2) problem-solving deficits; (3) intact WCST performance; and (4) deficits in set shifting.

Conclusions : The results support previous research indicating that the WCST is sensitive to three distinct cognitive processes: cognitive flexibility, problem-solving, and response maintenance. However, unlike the cognitive processes underlying WCST performance, the WCST scores representing these processes are not independent. The potential clinical relevance of these results is discussed.     

Mortality After Major Amputation Following Gangrene of the Lower Limb

Major amputations were performed on 310 patients because of gangrene of the lower limb. The mean age was 70 years and 58 per cent of the patients were males. Females were on average 5 years older.

The primary levels of amputation were above-knee (AK) in 33 per cent (103/310), through-knee (TK) in 21 per cent (66/310) and below-knee (BK) in 46 per cent (141/310).

Mortality during hospitalization was 18 per cent and the average hospitalization time 68 days. Mortality during hospital stay was primarily dependent on the occurrence of somatic complications, secondarily on the level of the amputation (as an expression of the extent of the gangrene) and finally on the age of the patient. The long-term survival rate was correlated primarily to the level of the amputation and secondarily to age. A high excess mortality was noted during the first few postoperative years, especially among AK amputees, but after this period the survival curve ran parallel to the expected survival rate. Mortality after 1 year was 34 per cent, comprising 17 per cent after BK amputation, 39 per cent after TK and 54 per cent after AK amputation.