Knut Harboe

Atypical femoral fractures in elderly women: a fracture registry-based cohort study

An atypical femoral fracture (AFF), with a transverse fracture radiologically through the lateral cortex is a rare but serious condition. In order to improve our ability to identify patients with this condition, we retrospectively surveyed all subtrochanteric, peri-implant and diaphyseal femoral fractures in patients aged ≥ 65 years who underwent surgical treatment at our hospital between 2004 and 2011. We describe the incidence of atypical fractures and their characteristics, with observational data including a review of the hospital and general practitioner records. Clinical outcomes were evaluated using the Harris hip score (HHS) and the timed up-and-go (TUG) test. Atypical fractures only occurred in women with an incidence of 9.8 per 100,000 person-years. The incidence in those who were treated with bisphosphonates was 79.0 per 100,000 person-years; eight of 17 fractures occurred around metal implants. There was a high incidence of delayed union and revision surgery. A total of nine patients (ten AFFs) were available for review at a mean follow-up of 36.5 months (10 to 104). The clinical outcome was poor with a mean HHS of 58.9 (95% CI 47.4 to 70.4) and a mean TUG test of 25.7 s (95% CI 12.7 to 38.8). The delay in diagnosis and treatment of AFF may result from a lack of knowledge of this condition.

How reliable and accurate is the AO/OTA comprehensive classification for adult long-bone fractures?

BACKGROUND Reliable classification of fractures is important for treatment allocation and study comparisons. The overall accuracy of scoring applied to a general population of fractures is little known. This study aimed to investigate the accuracy and reliability of the comprehensive Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association classification for adult long-bone fractures and identify factors associated with poor coding agreement. METHODS Adults (>16 years) with long-bone fractures coded in a Fracture and Dislocation Registry at the Stavanger University Hospital during the fiscal year 2008 were included. An unblinded reference code dataset was generated for the overall accuracy assessment by two experienced orthopedic trauma surgeons. Blinded analysis of intrarater reliability was performed by rescoring and of interrater reliability by recoding of a randomly selected fracture sample. Proportion of agreement (PA) and kappa (&kgr;) statistics are presented. Uni- and multivariate logistic regression analyses of factors predicting accuracy were performed. RESULTS During the study period, 949 fractures were included and coded by 26 surgeons. For the intrarater analysis, overall agreements were &kgr; = 0.67 (95% confidence interval [CI]: 0.64–0.70) and PA 69%. For interrater assessment, &kgr; = 0.67 (95% CI: 0.62–0.72) and PA 69%. The accuracy of surgeons’ blinded recoding was &kgr; = 0.68 (95% CI: 0.65– 0.71) and PA 68%. Fracture type, frequency of the fracture, and segment fractured significantly influenced accuracy whereas the coder’s experience did not. CONCLUSIONS Both the reliability and accuracy of the comprehensive Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association classification for long-bone fractures ranged from substantial to excellent. Variations in coding accuracy seem to be related more to the fracture itself than the surgeon. LEVEL OF EVIDENCE Diagnostic study, level I.

Steppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitment

BackgroundMusculoskeletal trauma represents a considerable global health burden, however reliable population-based incidence data are scarce. A fracture and dislocation registry was established within a well-defined population. An audit of the establishment process, feasibility of the registry work and report of the collected data is given.MethodsDemographic data, fracture type and location, mode of treatment, and the reasons for the secondary procedures were collected and scored using recognized systems, such as the AO/OTA classification and the Gustilo-Anderson classification for open fractures. The reporting was done in the operation planning program by the involved orthopaedic surgeon. Both inpatient and day-case procedures were collected. Data were collected prospectively from 2006 until 2010. Compliance among the surgeons and completeness and accuracy of the data was continuously assured by an orthopaedic surgeon.ResultsDuring the study period, 39 orthopaedic surgeons were involved in the recording of a total of 8,188 procedures, consisting of primary treatment of 4,986 long bone fractures, 467 non long bone fractures, 123 dislocations and 2,612 secondary treatments. In the study period 532 fractures or dislocations were treated at least once for one or more serious complications. For the index year of 2009, a total of 5710 fractures or dislocations were treated in the emergency department or hospitalized, of which the 1594 (28%) were treated at the inpatient or day-case operation rooms, thus registered in the FDR. Quality assurance, educational incentives and continuous feedback between coders and controller in the integrated electronic system are available and used through the features of the electronic database.ConclusionsImplementing an integrated registry of fractures and dislocations with the electronic hospital system has been possible despite several users involved. The electronic system and the data controller provide for completeness and validity. The FDR has become an indispensable tool for the department for planning and education and will serve as a prerequisite for the conduct and execution of future prospective trials within the department. Further, other departments with similar electronic patient files may fairly easily adopt this system for implementation.

Reliable classification of children’s fractures according to the comprehensive classification of long bone fractures by Müller

Background and purpose Guidelines for fracture treatment and evaluation require a valid classification. Classifications especially designed for children are available, but they might lead to reduced accuracy, considering the relative infrequency of childhood fractures in a general orthopedic department. We tested the reliability and accuracy of the Müller classification when used for long bone fractures in children. Methods We included all long bone fractures in children aged < 16 years who were treated in 2008 at the surgical ward of Stavanger University Hospital. 20 surgeons recorded 232 fractures. Datasets were generated for intra- and inter-rater analysis, as well as a reference dataset for accuracy calculations. We present proportion of agreement (PA) and kappa (K) statistics. Results For intra-rater analysis, overall agreement (κ) was 0.75 (95% CI: 0.68–0.81) and PA was 79%. For inter-rater assessment, K was 0.71 (95% CI: 0.61–0.80) and PA was 77%. Accuracy was estimated: κ = 0.72 (95% CI: 0.64–0.79) and PA = 76%. Interpretation The Müller classification (slightly adjusted for pediatric fractures) showed substantial to excellent accuracy among general orthopedic surgeons when applied to long bone fractures in children. However, separate knowledge about the child-specific fracture pattern, the maturity of the bone, and the degree of displacement must be considered when the treatment and the prognosis of the fractures are evaluated.

Incidence of traumatic long-bone fractures requiring inhospital management: a prospective age- and gender-specific analysis in 4,890 fractures

Background: Musculoskeletal trauma represents a considerable global health burden; however, reliable population-based incidence data are lacking. Thus, we prospectively investigated the age- and sex- specific incidence patterns of long-bone fractures in a defined population. Methods: A 4-year prospective study of all long-bone fractures in a defined Norwegian population was carried out. The demographic data, as well as data on fracture type and location and mode of treatment were collected using recognised classification (e.g., AO/OTA - Arbeitsgemeinschaft fur Osteosynthese- fragen/Orthopaedic Trauma Association; Gustilo-Anderson (GA) for open fractures). Age- and sex- adjusted incidences were calculated using population statistics. Results: During the study period, 4890 long-bone fractures were recorded. The overall incidence per 100,000 per year was 406 with a 95% confidence interval (95%CI) of 395-417. The age-adjusted incidence for those <16 years (339; 95%CI: 318-360) was lower than that for those � 16 years (427; 95%CI: 414- 440). The overall male incidence (337; 95%CI: 322-355) was lower than the female (476; 95%CI: 459- 493), but the male:female ratio was 2:1 among those <50 years, and 1:3 in those � 50 years. The upper limb fractures had an overall incidence of 159 (95%CI: 152-166), whereas the lower limb fracture incidence was 247 (95%CI: 238-256). Open fractures occurred in 3%, with an incidence of 13 (95%CI: 11- 15). Paediatric fractures were more likely to be treated conservatively with only 8% requiring internal fixation, compared to 56% internal fixation in those � 16 years of age. An increase in the use of angular stable plates occurred during the study period. Conclusion: This prospectively collected study of long-bone fractures in a defined population recognises age- and gender-specific fracture patterns. Boys predominate in the younger age group for which treatment is basically conservative. In the senior population, women and operative treatment predominate.

Development of a femoral stem providing strong anchorage and facilitated removal. An experimental study in goats.

OBJECTIVE Prosthetic elements must be securely anchored to bone. Should revision surgery be necessary, preservation of bone stock is crucial. The goal of this study was to develop and assess a femoral stem combining secure anchorage and facilitated removal in a goat model. METHODS The development of the uncemented femoral stem was part of an innovation process to fulfill the combined requirements. The stem was designed with two longitudinal semicircular grooves to accommodate a drill bit to unanchor the stem. These grooves were interconnected by canals, each 1 mm in diameter. The surface was partly coated with hydroxyapatite (HA). The stems were inserted in the left hip of 35 goats. Perioperatively, the grooves were filled with autologous bone grafts, and standard cemented canine acetabular component and head were used. The pull-out force was measured six months postoperatively. Following randomization, 11 animals had the grooves of the stem drilled to remove anchoring tissue. Twelve animals were left undrilled (controls). RESULTS There was a significant difference in mean pull-out force between the group that had been drilled (1526 N) compared with the controls (2033 N, p = 0.028). Most of the HA had been resorbed. CLINICAL SIGNIFICANCE The stems had a high retention force. The procedure for un-anchoring by drilling significantly reduced the pull-out force.