Bengt Borssén

Fractures After Stroke

Abstract. Fractures are a serious complication after stroke. Among patients with femoral neck fractures, a large subgroup have had a previous stroke. This study aimed to investigate the incidence of fractures after stroke. Included in the study were 1139 patients consecutively admitted for acute stroke. Fractures occurring from stroke onset until the end of the study or death were registered retrospectively. Hip fracture incidence was compared with corresponding rates from the general population. Patients were followed up for a total of 4132 patient-years (median 2.9 years). There were 154 fractures in 120 patients and median time between the onset of stroke and the first fracture was 24 months. Women had significantly more fractures than men (χ2 = 15.6; p < 0.001). In patients with paresis most of the fractures affected the paretic side (χ2 = 22.5; p < 0.001) and 84% of the fractures were cause by falls. Hip fracture was the most frequent fracture and the incidence was 2–4 times higher in stroke patients compared with the reference population. Fractures are thus a common complication after stroke. They are usually caused by falls and affect the paretic side. It is necessary to focus on the prevention of post-stroke fractures, including the prevention of both falls and osteoporosis.

Stroke, a Major and Increasing Risk Factor for Femoral Neck Fracture

BACKGROUND AND PURPOSE Patients with stroke have up to a 4-fold increased risk of hip fracture because of their high incidence of falls and loss of bone mass in the paretic side, ie, hemiosteoporosis. The purpose of this study was to investigate the prevalence of previous stroke among patients with femoral neck fracture. METHODS The study included all 568 patients, aged >/=65 years, who underwent surgery for femoral neck fracture in 1980, 1983, 1987, 1993, and 1997 at the orthopedic clinic of Umeå University Hospital, Umeå, Sweden. RESULTS The prevalence of previous strokes ranged from 16.4% to 38.5% (P<0.001); this finding is only partly explained by the increased incidence of stroke in the corresponding population, and there was no significant increase in the overall incidence of femoral neck fracture. Fractures occurred 5.4+/-6.4 years after stroke (median 2.9 years, range 0 to 33 years). In stroke patients with unilateral stroke and persisting paresis at the time of fracture, 62.5% had their fracture on the paretic side (P=0. 034). Survival was significantly reduced in patients with previous stroke (P<0.001). In patients previously independently mobile, 69.2% with no previous stroke and 38.1% with previous stroke were still mobile at discharge from the orthopedic unit (P<0.001). CONCLUSIONS Attention must be focused on stroke as a major and increasing risk factor for femoral neck fracture and also on the poor postfracture outcome and reduced survival of these patients. Prevention of poststroke fractures is necessary and is aimed at reducing the risk of poststroke fall and preventing the development of hemiosteoporosis.

Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study

Background and aims: Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. Methods: One hundred and ninety-nine patients, aged 70 years and over (mean age±SD, 82±6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. Results: The number of days of postoperative delirium among intervention patients was fewer (5.0±7.1 days vs 10.2±13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0±17.9 days vs 38.0±40.6 days, p=0.028). Conclusions: Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.

Prognostic factors in chondrosarcoma. A comparative study of cellular DNA content and clinicopathologic features

In a retrospective study of 45 surgically treated chondrosarcomas, the prognostic significance of the cellular DNA content and different clinicopathologic factors was analyzed both separately and in combination. The relationship between these parameters was also investigated. Diploid (normal DNA content) chondrosarcomas were associated with a significantly (P ≤ 0.001) higher ten‐year survival rate than hyperploid (abnormally increased DNA content) chondrosarcomas. Apart from ploidy, factors such as tumor size, tumor location and tumor grade also proved to be of prognostic importance. However, patients with diploid tumors had a better prognosis than those with hyperploid tumors, almost regardless of location, size, grade or even treatment. Nevertheless, additional prognostic information could be obtained by combining ploidy with size, location and grade of the tumors. Ploidy and treatment were significantly related to the ten‐year recurrence rate. No statistical relationship could be demonstrated between ploidy and other prognostic factors. A strong correlation (P ≤ 0.001) was, however, found between location and size of the tumors. Thus, distal tumors were significantly smaller and, moreover associated with a better prognosis than axial tumors. The results indicate that ploidy probably is the best predictor of the clinical course in chondrosarcoma. While tumor location and size may be assumed to determine the conditions for radical surgery, ploidy and grade seem to reflect the inherent biological malignancy in chondrosarcoma. Consideration of all these factors seems to provide not only valuable prognostic information, but also guidelines for treatment.

The Epidemiology of Foot Lesions in Diabetic Patients Aged 15–50 Years

All diabetic patients aged 15–50 years (n = 395) in the county of Umeå (population 118 500) were invited to have a standardized foot examination and 380 (96%) attended. Three‐quarters (78%) had Type 1 diabetes, 20% Type 2 diabetes, and 1% secondary diabetes. They were compared with 100 healthy control subjects. Both Type 1 and Type 2 diabetic patients had slight or moderate loss of forefoot arches more often than control subjects (57% and 60% vs 31%, p < 0.001). Callosities were not significantly more common in diabetic patients than in control subjects. Lesions observed on the lower legs and feet of the Type 1 and Type 2 diabetic patients were Melins shin spots (33% and 39%), dry feet (33% and 29%), yellow toenails (27% and 31%), purpura (9% and 5%), ulcers (3% and 0%), necrobiosis (3% and 0%), and diabetic osteopathy (2% and 0%). Intermittent claudication was present in 1% and 3%, respectively. Three Type 1 diabetic patients had undergone below‐knee amputation. Two of the control subjects had Melins shin spots. With the exception of necrobiosis which was only found in women with Type 1 diabetes and Melins shin spots which were twice as common in diabetic men as women, whether Type 1 or Type 2, lesions were equally distributed between the sexes. Sensory thresholds for vibration, perception, and pain were significantly elevated in Type 1 diabetic patients with dry feet, fallen forefoot arches or hammer toes compared with those without. They were not increased in Type 2 diabetic patients or control subjects with these lesions. In conclusion, foot deformity and lesions of skin and nails are common in the feet of diabetic patients in this age group while macroangiopathy appears to be uncommon.

Sensory thresholds for vibration, perception and pain in diabetic patients aged 15–50 years

The sensory thresholds for vibration, perception and pain were measured in 375/395 of all diabetic patients aged 15-50 years in Umeå county (population 118,500), 79% of whom had type 1 diabetes mellitus (DM). The results were compared with those from 100 healthy control subjects. Both type 1 and type 2 diabetic patients had significantly elevated sensory thresholds compared to control subjects. In multiple regression analysis, patients with type 1 DM had significant associations between elevated sensory thresholds and age, duration of diabetes, height but not with smoking. Type 2 diabetic patients had a significant association only with height and control subjects with age and height. Thresholds were significantly higher in men than in women with type 1 and type 2 DM and in control subjects but were no longer significant after normalizing for height. Thus, age, duration of DM and tall stature appear to be major risk factors and smoking a minor risk factor for elevation of sensory thresholds both in type 1 and type 2 DM and also in healthy control subjects. Gender differences depend on differences in height.

Preventive treatment of foot deformities in Type 1 diabetic patients aged 15–50 years – an epidemiological and prospective study

Objectives. To prevent worsening of foot deformities in diabetic patients.

Extensor digitorum brevis in diabetic neuropathy: a controlled evaluation in diabetic patients aged 15–50 years

Abstract. A reduction in the bulk of the extensor digitorum brevis muscle (EDB) may be a sign of diabetic neuropathy. We devised a semi‐quantitative scale (normal, reduced or absent) for assessing the bulk of the EDB muscle, and judged it to be a sign of neuropathy in 375 of 395 diabetic patients aged 15–50 years in the county of Umeå, 79% of whom had Type 1 diabetes mellitus (DM), and in 100 healthy controls. Reduced or absent EDB was significantly more common in patients with Type 1 and Type 2 DM than in controls (44 and 48 vs. 12%; P < 0.001). In patients with Type 1 DM, reduced or absent EDB was significantly correlated with age, longer duration of DM, smoking, dry feet, and foot ulcers, but not with fallen forefoot arch, hammer toes or callosities. Reduced or absent EDB was also associated with skin and nail lesions, including Melins shin spots, purpura and yellow toenails, but not with necrobiosis. Sensory thresholds for vibration, perception and pain were all significantly elevated in Type 1 diabetic patients with impaired EDB, compared to Type 1 diabetics with normal EDB. In controls, impaired EDB was only significantly correlated with smoking. We conclude that the EDB test is easy to perform, and may be used to screen for neuropathy in Type 1 diabetic patients.

The Association of Fibrinolysis and Hyperlipidaemia with Quantitative Sensory Tests in an Epidemiological Study of Swedish Type 1 Diabetic Patients

Serum levels of cholesterol, HDL‐cholesterol, triglycerides, lipoprotein Lp(a), and the fibrinolysis factors tPA (tissue plasminogen activator) and PAI‐1 activity (plasminogen activator inhibitor) were compared with sensory thresholds for vibration, electrical current perception, and pain in a population‐based study comprising 239 patients with diabetes mellitus Type 1, aged 15–50 years. Univariate regression analyses (n = 180) showed significant correlations between elevated sensory thresholds and age, duration of diabetes, serum cholesterol and triglycerides, and HbA1c. In multivariate regression analysis, age, duration of diabetes, height, and serum triglycerides showed significant independent associations with five or six of the six measured sensory threshold variables. In addition there was a significant association between increased thresholds for vibration and Lp(a) levels. Thus, increased sensory thresholds for vibration, current perception, and pain in patients with Type 1 diabetes are associated with increased serum triglyceride levels, and Lp(a) levels are associated with increased threshold for vibration. Fibrinolytic activity is unrelated to these measures of nerve function in Type 1 diabetic patients.