Bjarke Viberg

Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more

Background and purpose Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12–19 years of follow-up. Methods 4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991–1993) with 180 patients had undergone IF; cohort 2 (1991–1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991–1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991–1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex. Results Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9–7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1–4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8–7.4; RR = 16%). Interpretation Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.

Operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults: a systematic review

ObjectivesIntervention studies of clavicle fracture treatment are numerous, but only a few high quality studies prospectively compare operative and nonoperative treatment. The objective of this study was to review evidence from randomized controlled trials on operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults with focus on fracture healing, complications and functional outcome.Data sourcesAn electronic search was performed of PubMed, Embase and Cochrane databases which revealed 559 articles. All articles published before October 18th 2012 and written in English, Danish or Swedish were eligible.Study selectionArticles were excluded if they included children under the age of 16, did not include acute midshaft fractures, included concomitant fractures, did not meet the requirements of Level I evidence according to Centre for evidence based medicine 2009 guidelines, were systematic reviews or meta-analyses, or did not compare operative and nonoperative treatment.Data extractionArticles were parsed for relevance by two reviewers independently regarding title, abstract, and full text. Extraction of data was done by both reviewers in collaboration and sorted according to the aims of the study. Complications were grouped according to additional surgery required. The quality of studies was assessed by both reviewers in unison using Critical Appraisal Skills Programme 2010 checklists.ConclusionsIt seems like operative intervention leads to fewer nonunions at the cost of an increase in minor complications compared to nonoperative treatment. However, the effects of operation on functional outcome remains controversial. High quality evidence is currently sparse supporting either operative or nonoperative treatment on displaced midshaft clavicle fractures in adults.

Low bone mineral density is not related to failure in femoral neck fracture patients treated with internal fixation

Background and purpose — Internal fixation (IF) in femoral neck fractures has high reoperation rates and some predictors of failure are known, such as age, quality of reduction, and implant positioning. Finding new predictors of failure is an ongoing process, and in this study we evaluated the importance of low bone mineral density (BMD). Patients and methods — 140 consecutive patients (105 females, median age 80) treated with IF had a dual-energy X-ray absorptiometry (DXA) scan of the hip performed median 80 days after treatment. The patients’ radiographs were evaluated for fracture displacement, implant positioning, and quality of reduction. From a questionnaire completed during admission, 2 variables for comorbidity and walking disability were chosen. Primary outcome was low hip BMD (amount of mineral matter per square centimeter of hip bone) compared to hip failure (resection, arthroplasty, or new hip fracture). A stratified Cox regression model on fracture displacement was applied and adjusted for age, sex, quality of reduction, implant positioning, comorbidity, and walking disability. Results — 49 patients had a T-score below –2.5 (standard deviation from the young normal reference mean) and 70 patients had a failure. The failure rate after 2 years was 22% (95% CI: 12–39) for the undisplaced fractures and 66% (CI: 56–76) for the displaced fractures. Cox regression showed no association between low hip BMD and failure. For the covariates, only implant positioning showed an association with failure. Interpretation — We found no statistically significant association between low hip BMD and fixation failure in femoral neck fracture patients treated with IF.

Complications and functional outcome after fixation of distal tibia fractures with locking plate – A multicentre study

INTRODUCTION The aim of this study was to evaluate the proportion of complications and the functional outcome following ORIF with low-profile locking plates in patients with distal tibia fractures. METHOD Retrospective data was retrieved using county databases, operation books, health record and X-ray images for 6 hospitals (1 level 1, 5 level 2) in the Region of Southern Denmark. Between January 2007 and April 2011 70 consecutive patients with 71 distal tibia fractures were treated with low-profile locking plate were included. The proportion of post-operative complications, classified as minor and major complications, was retrieved from electronic health records and patient interviews. Long-term functional outcome assessed by EuroQol EQ-5D-5L questionnaire, AOFAS Ankle-Hindfoot scale, and return to pre-injury job function through patient interview and examination. RESULTS There were 32 43A, 5 43B and 34 43C-fractures, 12 open and 10 high-energy fractures. Forty-nine cases (69%) experienced complications during the follow-up time, of which 34 were minor complications and 15 were major complications. Median EQ-5D-5L index value was 0.76, median EQ VAS-score was 80, and median AOFAS score was 73. Thirty-three percent of working patients had not returned to work as a result of the fracture. CONCLUSIONS Our study suggest that treatment of distal tibia fractures with low-profile locking plates might have a higher proportion of complications and worse functional outcome than previously reported. LEVEL OF EVIDENCE Therapeutic level IV Case Serie.

Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis

&NA; Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta‐analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta‐analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively. &NA; Level of Clinical Evidence: 1

Can intermittent pneumatic compression (IPC) reduce time to surgery for malleolar fractures

BACKGROUND Surgery of malleolar fractures are often delayed due to oedema of the ankle. The use of intermittent pneumatic compression (IPC) is thought to reduce oedema of the fracture site and thereby time to surgery in patients with malleolar fractures. PURPOSE To investigate the influence of IPC on the time from admission to surgery in adult patients with internal fixated primary malleolar fractures. METHODS February 1st 2013 IPC was introduced as a standard treatment for all patients admitted with a malleolar fracture. Data was retrieved from the hospital database 2 years prior and after the introduction date. The patients were found using ICD-10 diagnoses codes (DS825-8) in combination with NOMESCO procedure codes (KNHJ40-3, KNHJ60-3, KNHJ70-3, KNHJ80-3). One reviewer examined all the journals and classified the x-ray images by the AO classification. The primary outcome measure was time from diagnosis to surgery. RESULTS 74 patients in the IPC cohort and 113 in the non-IPC cohort were included in the study. Time from admission to surgery was 21.9 (10.8-45.0) hours in the control group and 22.1 (8.9-41.2) hours in the IPC group. The difference is not statistically significant (p=0.420). A subgroup analysis divided the patients operated before and after 24h from admission. The median (IQR) time to surgery for patients operated before 24h was 10.9 (6.4-16.9) hours for the control group and 9.9 (5.8-20.1) hours in the IPC group (p=0.989). The median (IQR) time to surgery for patients operated after 24h was 21.5 (4.1-57.0) hours for the control group and 18.4 (7.4-32.3) hours in the IPC group (p=0.353). INTERPRETATION There was no benefit from IPC on time to surgery in patients with acute primary malleolar fracture in a cohort with a mean surgical delay less than 24h.

Poor relation between biomechanical and clinical studies for the proximal femoral locking compression plate: A systematic review

Background and purpose — The proximal femur locking compression plate (PF-LCP) is a new concept in the treatment of hip fractures. When releasing new implants onto the market, biomechanical studies are conducted to evaluate performance of the implant. We investigated the relation between biomechanical and clinical studies on PF-LCP. Methods — A systematic literature search of relevant biomechanical and clinical studies was conducted in PubMed on December 1, 2015. 7 biomechanical studies and 15 clinical studies were included. Results — Even though the biomechanical studies showed equivalent or higher failure loads for femoral neck fracture, the clinical results were far worse, with a 37% complication rate. There were no biomechanical studies on pertrochanteric fractures. Biomechanical studies on subtrochanteric fractures showed that PF-LCP had a lower failure load than with proximal femoral nail, but higher than with angled blade plate. 4 clinical studies had complication rates less than 8% and 9 studies had complication rates between 15% and 53%. Interpretation — There was no clear relation between biomechanical and clinical studies. Biomechanical studies are generally inherently different from clinical studies, as they examine the best possible theoretical use of the implant without considering the long-term outcome in a clinical setting. Properly designed clinical studies are mandatory when introducing new implants, and they cannot be replaced by biomechanical studies.

Does different duration of non-operative immobilization have an effect on the redislocation rate of primary patellar dislocation?: A retrospective multicenter cohort study

BACKGROUND Immobilization devices such as plaster splints, casts and braces have been used for first time patellar dislocation (FTPD) in order to prevent redislocation. This study evaluates different non-operative immobilization regimes upon rates of redislocation. METHODS A retrospective cohort study with a study population of 1366 in which 601 subjects under 30years with FTPD were included from three hospitals. Exclusion criteria were osteochondral fracture, ligament injury and subluxation. Subjects were divided into five groups; unknown/none, two weeks of brace, two weeks of brace followed by bandage, four weeks of brace and six weeks of brace with increasing of range of motion. Radiographs were evaluated for trochlear dysplasia (TD), patella alta, trochlear depth and growth zone. Crude analysis and logistic regression adjusted for radiographic assessments, age, gender and rehabilitation was done in STATA® with significance p≤0.05. RESULTS Forty-five point eight percent were between 15 and 19years and 51.4% were male. One hundred sixty-three experienced redislocation (27.1%). Logistic regression was performed at 404 subjects and showed that rehabilitation, gender, TD, patella alta, and growth zone had no significant odds ratio (OR) on redislocation. The duration of brace demonstrated no significant OR in reducing redislocation. Subjects between 20 and 29years showed lower OR in redislocation (95% CI) of 0.27 (0.11; 0.64, p=0.003). CONCLUSION This study demonstrated no difference in duration of brace treatment in reducing patella redislocation after FTPD. Rehabilitation and predisposal factors such as TD, trochlear depth, patella alta and open growth zone did not influence the redislocation rate. Increasing age reduced risk of redislocation.

Hip fractures in the non-elderly—Who, why and whither?

Nonelderly hip fracture patients have gathered little scientific attention, and our understanding of the group may be biased by patient case-mix and lack of follow-up. Preconceptions may thwart adequate investigation of bone health and other comorbidities. This literature review focusses on who these patients between 20 and 60 years are, how to treat them and how to evaluate the outcome. 2-11% of the hip fractures occur in non-elderly, equally common in men and women. Every second to forth patient smoke, have chronic diseases, and abuse alcohol. Poor self-rated health, sleep disturbances, low cognitive function and education are associated with increased hip fracture risk in young adults. Bone health is poorly investigated, but literature suggest young patients to have lower bone mineral density regardless of trauma mechanism. Studies contradict on whether surgery within 8-12 h reduce the risk of avascular necrosis in femoral neck fractures (FNF). Based on rationality, surgery ought to be performed promptly, in order to reduce pain and permit rehabilitation. There is no convincing support from the existing literature to use open reduction. Good reduction is mandatory, preferably using a closed reduction technique. The failure rate following internal fixation of displaced FNF in younger patients can be as high as 59%. In some cases a displaced FNF is better treated with a primary arthroplasty; in case of rheumatoid arthritis or osteoarthritis for example. Complications after extracapsular fractures vary from 6 to 23%. The relatively few studies looking at functional outcome in non-elderly use a multitude of outcome measures, precluding comparisons. Many non-elderly patients seem not to fully recover. While some non-elderly hip fracture patients are healthy individuals sustaining high energy trauma, others have low-energy fractures and comorbidities including reduced bone strength (either as a primary or secondary condition). i.e. non-delaying medical optimization, proper surgical technique, bone health investigation and secondary fracture prevention is necessary. Younger hip fracture patients are at risk of permanent loss of function, and negative socioeconomic and psychological consequences. High-energy trauma does not exclude the presence of osteopenia. A hip fracture in adulthood and middle-age is very seldom caused by bad luck only!

Tourniquet use in lower limb fracture surgery: a systematic review and meta-analysis

BackgroundTourniquets are commonly used in today’s orthopaedic surgical practice, but little evidence is available regarding the links between the use of a tourniquet and the amount of post-operative pain and other complications. The aim of the study was to conduct a systematic review and meta-analysis comparing tourniquet versus non-tourniquet use during fracture surgery of the lower limb in adult patients.MethodA search was performed using the keyword “tourniquet” in EmBase and as a MeSH term in PubMed, and no limitations (including language) were applied. Available studies were screened using the Covidence software, and demographic as well as outcome data were extracted from the final studies. Critical appraisal was performed according to Cochrane Risk of Bias guidelines. Pooled data were assessed for heterogeneity using Chi-squared and I2 tests.ResultsFive studies were included, and no statistically significant difference was found in the amount of pain and post-operative complications between tourniquet and non-tourniquet groups. Length of in-hospital stay was longer in the tourniquet groups. An overall high risk of bias was found in the included studies.ConclusionAlthough the validity and statistical strength of our results are not strong enough to suggest a change in practice in tourniquet use, the operating surgeon should still carefully consider his or her decision to use a tourniquet in lower limb fracture surgery, as there are indeed complications associated with it and no current evidence to support its continued use.Level of evidenceLevel I, systematic review of randomized controlled trials.