Eva Samnegård

Effect of smoking cessation intervention on results of acute fracture surgery: a randomized controlled trial.

BACKGROUND Tobacco smoking is a major health and economic concern and is also known to have a significant negative effect on surgical outcomes. The benefits of a smoking cessation intervention prior to elective orthopaedic surgery have been evaluated previously. Our aim was to assess whether a smoking cessation program, initiated during the acute hospitalization period and carried out for six weeks, could reduce the number of complications following emergency surgical treatment of fractures. METHODS In a multicenter, single-blinded, randomized, controlled clinical trial, 105 smokers with a fracture of the lower or upper extremity that needed acute surgical treatment were randomized to an intervention group (n = 50) or a control group (n = 55). The intervention group was offered a standardized smoking cessation program for six weeks, and all patients were followed at two to three weeks, four weeks, and six to twelve weeks. RESULTS The proportion of patients with at least one postoperative complication was significantly larger in the control group than it was in the intervention group (38% and 20%, respectively; p = 0.048). The development of two or more postoperative complications was also more common among the controls (p = 0.039). The rates of superficial wound infection, the most frequently recorded complication in both groups, were 20% and 8%, but this difference was not significant. A secondary analysis showed that the odds of having a complication were 2.51 times (95% confidence interval, 0.96 to 6.9 times) higher in the control group than in the intervention group, but this difference was not significant. CONCLUSIONS Our results indicate that a smoking cessation intervention program during the first six weeks after acute fracture surgery decreases the risk of postoperative complications.

Quality of life after a subtrochanteric fracture A prospective cohort study on 87 elderly patients

BACKGROUND The subtrochanteric fracture constitutes approximately 5-10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures. OBJECTIVE To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL. SETTING Four university hospitals. DESIGN A prospective cohort study with a 2-year follow-up. PATIENTS AND METHODS Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5D(index) score). RESULTS The EQ-5D(index) score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months. CONCLUSIONS A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs).

Gender differences and cognitive aspects on functional outcome after hip fracture—a 2 years’ follow-up of 2,134 patients

BACKGROUND hip fractures as well as cognitive dysfunction become increasingly prevalent in growing ageing populations. Hip fractures are approximately three times more common in elderly women. OBJECTIVE we analysed outcome after hip fracture with respect to gender and cognitive function. DESIGN population-based, prospective cohort study. SETTING four university hospitals in Stockholm, Sweden. SUBJECTS a total of 2,134 consecutive patients admitted with hip fracture during 2003. METHODS gender differences in residence, walking ability and activity of daily living (ADL) were analysed at baseline, after 4 and 24 months in patients with and without intact cognitive function. RESULTS women were older, more often living alone and had poorer walking ability (P < 0.001). Cognitive dysfunction was equally common by gender. Women were more often treated with a prosthesis (P < 0.001) and sent to rehabilitation (P < 0.001). In the cognitive dysfunction group, men had more co-morbidity (P < 0.001) and total loss of walking ability (P = 0.03), but more often resided in own homes (P = 0.03). There was no gender difference in ADL. CONCLUSION men had a higher risk for loss of walking ability and death only in patients with cognitive dysfunction. Cognitive function was the most important factor for returning to own home and regain pre-fracture function.

Does Rehabilitation Matter in Patients With Femoral Neck Fracture and Cognitive Impairment? A Prospective Study of 246 Patients

UNLABELLED Al-Ani AN, Flodin L, Söderqvist A, Ackermann P, Samnegård E, Dalén N, Sääf M, Cederholm T, Hedström M. Does rehabilitation matter in patients with femoral neck fracture and cognitive impairment? A prospective study of 246 patients. OBJECTIVE To identify factors associated with preserved walking ability and Katz activities of daily living (ADLs) index at 4-month and 12-month follow-up in cognitively impaired patients with femoral neck fracture. DESIGN Population-based cohort study. SETTING A multicenter study of the Stockholm Hip Fracture Group including 4 university hospitals. PARTICIPANTS Consecutive patients (N=246) with femoral neck fracture, older than 65 years (mean, 84y; 72% women) with cognitive impairment (known dementia or low [0-2 points] score) in Short Portable Mental Status Questionnaire [0-10 points]) and able to walk before the fracture. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Walking ability and ADLs index at 4-month and 12-month follow-up. RESULTS Significant predictors of preserved walking ability at 12-month follow-up were discharge to rehabilitation unit (odds ratio [OR]=2.83; confidence interval [CI], 1.1-7.26; P=.03) and walking ability before the fracture (OR=8.98; CI, 3.52-22.93; P<.001), while type of surgery was not (P=.197). Analyses were adjusted for age, sex, American Society of Anesthesiologists score, fracture type, and surgical method. Corresponding predictors of preserved Katz ADLs index at 12-month follow-up, after adjustment for age and sex, were discharge to rehabilitation unit (OR=5.33; CI, 1.44-19.65; P=.012) and ADLs index before fracture (OR=2.51; CI, 1.8-3.5; P<.001), while type of surgery was not (P=.376). CONCLUSIONS Discharge to rehabilitation unit, a factor we can influence, was associated with preserved walking ability and ADLs index in cognitively impaired patients with hip fracture.

Quality of life after a stable trochanteric fracture--a prospective cohort study on 148 patients.

Objective: The aim of this study was to report the long-term outcome for patients with stable trochanteric fractures, especially regarding the health-related quality of life (HRQoL). Design: A prospective cohort study with a 2-year follow-up. Setting: Four university hospitals. Patients: One hundred forty-eight consecutive patients with stable trochanteric fractures, that is, a 2-part fracture (J-M 1 and 2) according to the Jensen-Michaelsen classification, treated with a sliding hip screw. Main Outcome Measurements: Mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function, and HRQoL assessed with the EuroQol-5D (EQ-5Dindex score). Results: The 2-year mortality rate was 29%. The reoperation rate was 3%. At the final follow-up, 81% of the patients reported no or only limited pain at the hip, 55% had regained their prefracture walking ability, and 66% their prefracture level of ADL function. The EQ-5Dindex score decreased from 0.69 before the fracture to 0.57 at 4 months, 0.59 at 12 months, and 0.66 at 24 months. Conclusions: Besides the expected mortality rate, the results of the study confirm a low reoperation rate and a good outcome regarding pain at the hip and only limited deterioration in HRQoL after a stable trochanteric fracture. However, a considerable number of the patients experienced deterioration in their walking ability and ADL function. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life years.

Screw positions in femoral neck fractures: Comparison of two different screw positions in cadavers

To evaluate the influence of different screw positions on the stability of fixation in femoral neck fractures, 30 cadaveric proximal femora were osteotomized and fixed with 2 cannulated screws. The proximal screw was placed either with a posterior cortical support in the femoral neck or centrally, supported only by cancellous bone. The distal screw rested on the femoral calcar. The specimens were tested in bending, using the force at 2 and 5 mm deflection at the osteotomy site and at fracture, as an expression of the stability of fixation. The test sequences were recorded on a x-y plotter and on videotape. Bone density measurements were made at the femoral neck, Wards triangle, and the trochanter region. Our findings indicate that a posterior position with cortical support for the proximal screw, compared to a central screw position with only cancellous bone support, increases the stability of femoral neck fractures.

Verapamil induces increased bone volume and osteopenia in female rats but has the opposite effect in male rats

SummaryVerapamil inhibits the intestinal absorption of calcium (Ca) and increases serum parathyroid hormone in rats. The effects of verapamil on bone tissue after long-term treatment is, however, not well described. Adult female and male Sprague-Dawley rats received verapamil in their drinking water at a dosage of 0.075 mg/ml (low dose) or 0.75 mg/ml (high dose) for 12 weeks; control rats received only drinking water. All rats were fed a diet containing 0.1% Ca and 0.5% P. In female rats, the amount of bone ash per volume was significantly reduced from 0.742 g/ml in controls to 0.713 g/ml after low-dose treatment of verapamil, and to 0.667 g/ml following high-dose treatment (P<0.01). The tibial length was increased from 39.7 mm in controls to 40.3 mm or to 40.7 mm after low or high doses (P<0.01). The tibial volume increased from 0.385 ml in controls to 0.397 ml after low doses and to 0.429 ml after high doses (P<0.01). In contrast, in male rats the amount of bone ash per volume was significantly increased from 0.578 g/ml in controls to 0.580 g/ml after low doses and to 0.620 g/ml after high doses of verapamil (P<0.01). The tibial bone volume in males as decreased from 0.633 ml in controls to 0.641 ml after low doses and to 0.583 ml after high doses (P<0.05). The tibial length in the males was not changed by verapamil. The intestinal absorption of Ca was reduced in male rats from 5.28 in controls to 4.03 (serosa/mucosa) after low-dose treatment and to 2.46 after high-dose treatment with verapamil (P<0.05). In female rats, the intestinal absorption of Ca did not change after verapamil treatment. Thus, chronic treatment with verapamil in female rats induced osteopenia whereas in male rats bone growth was inhibited.

Differential Bone Turnover in an Angulated Fracture Model in the Rat

We have developed a simple rat model of angulated tibial fracture which elicits substantial differences in bone formation and resorption within the same bone. In 35 rats the right mid-tibia was manually fractured and fixed with an intramedullary 17-gauge cannula needle. Twenty tibias were fixed in anterior angulation (27 ± 5°) and 15 in posterior angulation (31 ± 5°). Serial X-rays were taken over a 12-week period. All fractures healed completely within five weeks. In both groups, bone thickness was already significantly greater on the concave side than on the convex side at week 3 and remained so until the end of the experiment. The thickness on the convex side decreased dramatically within 3 to 5 weeks and gradually thereafter. For morphological analysis of bone mineralization, 3 rats from each group were given calcein and alizarin red injected at different time points up to 14 weeks. Maximum new bone formation was noted within the first 3 weeks. Over the ensuing weeks, new bone formation remained intense on the concave side, but it was virtually absent on the convex side. These results show that angulated fracture deformity reproducibly exhibits differential bone turnover, which can be exploited in research on local regulatory factors. To exemplify the utility of the model, an immunohistochemical study on two local markers was done. Callus tissue of five rats in the anterior angulation group at week 3 post-fracture was stained for the cytokine IL-1β, a stimulator of bone resorption, and the neuropeptide CGRP, an inhibitor of resorption, showing clear differences in positive staining between the concave and convex sides. Our in-vivo model offers a means of analyzing morphologically and quantitatively the differential expression and action of factors involved in local bone turnover.

Additive effects of nutritional supplementation, together with bisphosphonates, on bone mineral density after hip fracture: a 12-month randomized controlled study

Background After a hip fracture, a catabolic state develops, with increased bone loss during the first year. The aim of this study was to evaluate the effects of postoperative treatment with calcium, vitamin D, and bisphosphonates (alone or together) with nutritional supplementation on total hip and total body bone mineral density (BMD). Methods Seventy-nine patients (56 women), with a mean age of 79 years (range, 61–96 years) and with a recent hip fracture, who were ambulatory before fracture and without severe cognitive impairment, were included. Patients were randomized to treatment with bisphosphonates (risedronate 35 mg weekly) for 12 months (B; n=28), treatment with bisphosphonates along with nutritional supplementation (40 g protein, 600 kcal daily) for the first 6 months (BN; n=26), or to controls (C; n=25). All participants received calcium (1,000 mg) and vitamin D3 (800 IU) daily. Total hip and total body BMD were assessed with dual-energy X-ray absorptiometry at baseline, 6, and 12 months. Marker of bone resorption C-terminal telopeptide of collagen I and 25-hydroxy vitamin D were analyzed in serum. Results Analysis of complete cases (70/79 at 6 months and 67/79 at 12 months) showed an increase in total hip BMD of 0.7% in the BN group, whereas the B and C groups lost 1.1% and 2.4% of BMD, respectively, between baseline and 6 months (P=0.071, between groups). There was no change in total body BMD between baseline and 12 months in the BN group, whereas the B group and C group both lost BMD, with C losing more than B (P=0.009). Intention-to-treat analysis was in concordance with the complete cases analyses. Conclusion Protein-and energy-rich supplementation in addition to calcium, vitamin D, and bisphosphonate therapy had additive effects on total body BMD and total hip BMD among elderly hip fracture patients.

Spontaneous correction of angular fracture deformity in the rat

Background The different parts of long bone are known to participate in the spontaneous correction of fracture deformity. However, the relative contribution of growth plate, epiphysis and diaphysis of bone during the correction process is not clear. Animals and methods We used a rat model of tibial fracture fixed with a semi-rigid intramedullary pin in anterior angulation, and evaluated the magnitude, temporal course and pertinent sites of spontaneous deformity correction by means of radiography and bone mineral uptake. Results Over a 12-week period, the mean angular deformity was corrected from 27° to 11°. The major portion of the correction (14° of 16°) occurred within 3 weeks, concomitantly with fracture healing. The angle of the proximal growth plate changed 8° over the study period. The first 3 weeks were characterized by intense bone formation on the concave side of the fracture. From weeks 3–8, signs of resorption predominated on the corresponding convex side. On the concave side, the front of new bone formation in the proximal diaphysis moved in the opposite direction to that at the fracture level, so that both sites contributed to deformity correction. Interpretation We found that different sites of a diaphyseal bone fractured in angulation respond quite differently, but still in an orchestrated way to promote correction by modeling. Notably, most of the spontaneous correction occurred during the reparative phase, the major contributor being the diaphysis, not the growth plate. Compared to other reports on angulated fracture using rigid fixation and limb immobilization, our data suggest that semi-rigid fixation and early weight bearing is more efficient in enhancing not only healing, but also deformity correction.