Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients.

BACKGROUND: Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality. METHODS: All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. RESULTS: A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18-94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2). CONCLUSIONS: Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality.

Musculoskeletal injuries in trauma patients: a Swedish nationwide register study including 37,266 patients.

BACKGROUND AND PURPOSE: Trauma causes over 4 million annual deaths globally and accounts for over 10% of the global burden of disease. Trauma patients often sustain multiple injuries in multiple organ systems. We aimed to investigate the proportion and distribution of musculoskeletal injuries in adult trauma patients. PATIENTS AND METHODS: This is a register-based study using data from the national Swedish trauma register (SweTrau) collected in 2015-2019. By categorizing Abbreviated Injury Scale (AIS) codes into different injury types, we provide a detailed description of the types of musculoskeletal injuries that occurred in trauma patients. RESULTS: 51,335 cases were identified in the register. After exclusion of 7,696 cases that did not have any trauma diagnosis (AIS codes) registered from the trauma and 6,373 patients aged < 18, a total of 37,266 patients were included in the study. 15,246 (41%) had sustained musculoskeletal injury. Of the patients with musculoskeletal injuries, 7,733 (51%) had more than 1 such injury. Spine injuries were the most common injury location (n = 7,083 patients, 19%) followed by lower extremity injuries (n = 5,943 patients, 16%) and upper extremity injuries (n = 6,273 patients, 17%). Fractures were the dominating injury type with 30,755 (87%) of injuries being a fracture. CONCLUSION: 41% of the trauma patients had at least 1 musculoskeletal injury. A spine injury was the most common injury location. Fractures was the dominating injury type constituting 87% of all injuries. We also found that half the patients (51%) with spine or extremity injuries had ≥ 2 such injuries.

Complications after surgical treatment of pelvic fractures: a five-year follow-up of 194 patients.

PURPOSE: Surgical treatment of pelvic fractures is an advanced intervention associated with multiple complications. The primary aim of this study was to investigate the rate of unplanned reoperations after pelvic fracture surgery. Secondary aims included occurrence of other adverse events and mortality. METHODS: All adult patients ≥ 18 years with surgically treated pelvic fracture operated at the Karolinska University Hospital in Sweden between 2010 and 2019 were identified and retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. RESULTS: A total of 194 patients were included with mean age (± SD, range) 45.4 (16, 18-83) years. 62% were males (n = 121) and the median (IQR) follow-up time was 1890 (1791) days (4.9 years). Forty-eight patients (25%) had an unplanned reoperation, with infection being the most common cause of reoperation (n = 18, 9.3%). Seventy-eight (40%) patients had an adverse event not requiring reoperation and the most common event was nerve injury (n = 34, 18%). Concomitant abdominal injury was identified as a risk factor for an adverse event (OR 2.5, 95% CI 1.3-4.9, p < 0.01). 30-day mortality was 1.5% and 1-year mortality 6.2%. CONCLUSION: The rate of unplanned reoperation after pelvic fracture surgery was high, as was the rate of other adverse events not requiring surgery. No identified risk factor was found to predict further surgery, but concomitant abdominal injury was a risk factor for other adverse events. Mortality was low at both 30 days and 1 year.

Complications after surgical treatment of acetabular fractures: a 5-year follow-up of 229 patients.

PURPOSE: Acetabular fractures are injuries often surgically treated, but the surgical intervention is associated with a high risk of subsequent complications. The primary aim of this study was to explore the rate of reoperations and to identify potential risk factors for reoperation. Secondary aims were other adverse events and mortality. METHODS: Patients ≥ 18 years with a surgically treated acetabular fracture at a single trauma center in Sweden between 2010 and 2019 were retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to investigate factors associated with reoperations and other adverse events. RESULTS: A total of 229 patients with a surgically treated acetabular fracture were included, mean age (± SD, range) 60 (19, 19-94) years. The majority of the patients were males (n = 180, 79%), and the median (IQR) follow-up time was 1779 (1906) days (4.9 years). 47 patients (21%) underwent a reoperation. THA as surgical method was associated with a lower reoperation rate compared to ORIF (OR 0.3, 95% CI 0.1-0.8, p < 0.01). 72 patients (31%) sustained an adverse event not requiring reoperation, and admittance to ICU was associated with an increased risk (OR 2.6, 95% CI 1.2-5.7, p = 0.02). 30-day mortality was 3.1% and 1-year mortality 5.7%. CONCLUSION: The complication rate after acetabular fracture surgery was high, and surgical treatment with primary THA was associated with a reduced risk for reoperation.

Influence of perioperative SARS-CoV-2 infection on mortality in orthopaedic inpatients with surgically treated traumatic fractures.

BACKGROUND: SARS-CoV-2 has had an extensive influence on orthopaedic surgery practice and has been associated with an increased risk of mortality. There is limited evidence of how this pertains to acute orthopaedic surgery with inpatient care. METHODS: A retrospective cohort study on traumatic fracture patients requiring inpatient care between February 25, 2020 and March 25, 2021 was conducted. Patients were grouped by perioperative SARS-CoV-2 infection, defined as a positive SARS-CoV-2 test from 7 days before to 7 days after orthopaedic surgery, and compared using linear regression and Cox proportional hazards model for primary outcome 30-day mortality and secondary outcome hospital length of stay. RESULTS: In total, 5174 adults with a length of stay ≥ 48 h and an orthopaedic procedure due to a registered traumatic fracture were admitted from February 25, 2020 and discharged before March 26, 2021. Among the 5174 patients, 65% (3340/5174) were female, 22% (1146/5174) were 60-74 years and 56% (2897/5174) were 75 years or older. In total, 144 (3%) had a perioperative SARS-CoV-2 infection. Perioperative SARS-CoV-2 infection was associated with an increased 30-day mortality (aOR 4.19 [95% CI 2.67-6.43], p < 0.001). The median (IQR) length of stay after surgery was 13 days (IQR 6-21) for patients with, and 7 days (IQR 2-13) for patients without, perioperative SARS-CoV-2 infection. CONCLUSIONS: Perioperative SARS-CoV-2 infection increased 30-day mortality risk and hospital length of stay for traumatic fracture patients requiring inpatient surgical care. Pre- and postoperative infection were both associated with similar increases in mortality risk.

Computed tomography micromotion analysis in the follow-up of patients with surgically treated pelvic fractures: a prospective clinical study.

PURPOSE: High-energy pelvic fractures are complex injuries often requiring surgical treatment. Different radiological methods exist to evaluate the reduction and healing process postoperatively but with certain limitations. The aim of this study was to evaluate Computed Tomography Micromotion Analysis (CTMA) in a clinical setting for follow-up of surgically treated pelvic fracture patients. METHODS: 10 patients surgically treated for a pelvic fracture were included and prospectively followed with Computed Tomography (CT) at 0, 6, 12 and 52 weeks postoperatively. CTMA was used to measure postoperative translation and rotation of the pelvic fracture during the 52 weeks follow-up. Clinical outcomes were collected through the questionnaires EQ-5D index score and Majeed score. RESULTS: 10 patients were included with mean age (± SD, min-max) 52 (16, 31-80) years and 70% (n = 7) were males. The median (IQR, min-max) global translation from 0 to 52 weeks was 6.0 (4.6, 1.4-12.6) millimeters and median global rotation was 2.6 (2.4, 0.7-4.7) degrees. The general trend was a larger translation between 0 and 6 weeks postoperatively compared to 6-12 and 12-52 weeks. For the clinical outcomes, the general trend was that all patients started from high scores which decreased in the first postoperative follow-up and recovered to different extent during the study period. CONCLUSION: CTMA was successfully used in the follow-up of surgically treated pelvic fracture patients. Movement in the pelvic fractures after surgical fixation was largest between 0 and 6 weeks.

Epidemiology and mortality of pelvic and femur fractures-a nationwide register study of 417,840 fractures in Sweden across 16 years: diverging trends for potentially lethal fractures.

Background and purpose - Fractures of the pelvis and femur are serious and potentially lethal injuries affecting primarily older, but also younger individuals. Long-term trends on incidence rates and mortality might diverge for these fractures, and few studies compare trends within a complete adult population. We investigated and compared incidence and mortality rates of pelvic, hip, femur shaft, and distal femur fractures in the Swedish adult population.Patients and methods - We analyzed data on all adult patients ≥ 18 years in Sweden with a pelvic, hip, femur shaft, or distal femur fracture, through the Swedish National Patient Register. The studied variables were fracture type, age, sex, and 1-year mortality.Results - While incidence rates for hip fracture decreased by 18% (from 280 to 229 per 105 person-years) from 2001 to 2016, incidence rates for pelvic fracture increased by 25% (from 64 to 80 per 105 person-years). Incidence rates for femur shaft and distal femur fracture remained stable at rates of 15 and 13 per 105 person-years respectively. 1-year mortality after hip fracture was 25%, i.e., higher than for pelvic, femur shaft, and distal femur fracture where mortality rates were 20-21%. Females had an almost 30% lower risk of death within 1 year after hip fracture compared with males.Interpretation - Trends on fracture incidence for pelvic and femur fractures diverged considerably in Sweden between 2001 and 2016. While incidence rates for femur fractures (hip, femur shaft, and distal femur) decreased or remained constant during the studied years, pelvic fracture incidence increased. Mortality rates were different between the fractures, with the highest mortality among patients with hip fracture.

Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients.

BACKGROUND: Surgical site infections (SSI) after distal radius fracture (DRF) surgery have not previously been studied as the primary outcome in a large population with comparative data for different surgical methods. The aims of this study were 1) to compare SSI rates between plate fixation, percutaneous pinning and external fixation, and 2) to study factors associated with SSI. METHODS: We performed a nation-wide cohort study linking data from the Swedish national patient register (NPR) with the Swedish prescribed drug register (SPDR). We included all patients ≥18 years with a registration of a surgically treated DRF in the NPR between 2006 and 2013. The primary outcome was a registration in the SPDR of a dispensed prescription of peroral Flucloxacillin and/or Clindamycin within the first 8 weeks following surgery, which was used as a proxy for an SSI. The SSI rates for the three main surgical methods were calculated. Logistic regression was used to study the association between surgical method and the primary outcome, adjusted for potential confounders including age, sex, fracture type (closed/open), and a dispensed prescription of Flucloxacillin and/or Clindamycin 0-8 weeks prior to DRF surgery. A classification tree analysis was performed to study which factors were associated with SSI. RESULTS: A total of 31,807 patients with a surgically treated DRF were included. The proportion of patients with an SSI was 5% (n = 1110/21,348) among patients treated with plate fixation, 12% (n = 754/6198) among patients treated with percutaneous pinning, and 28% (n = 1180/4261) among patients treated with external fixation. After adjustment for potential confounders, the surgical method most strongly associated with SSI was external fixation (aOR 6.9 (95% CI 6.2-7.5, p < 0.001)), followed by percutaneous pinning (aOR 2.7 (95% CI 2.4-3.0, p < 0.001)) (reference: plate fixation). The classification tree analysis showed that surgical method, fracture type (closed/open), age and sex were factors associated with SSI. CONCLUSIONS: The SSI rate was highest after external fixation and lowest after plate fixation. The results may be useful for estimation of SSI burdens after DRF surgery on a population basis. For the physician, they may be useful for  estimating the likelihood of SSI in individual patients.

Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an observational study of 23,394 fractures from the national Swedish fracture register.

BACKGROUND: Distal radius fractures are the most common of all fractures. Optimal treatment is still debated. Previous studies report substantial changes in treatment trends in recent decades. Few nation-wide studies on distal radius fracture epidemiology and treatment exist, none of which provide detailed data on patient and injury characteristics, fracture pattern and mortality. The aim of this study was to describe the epidemiology, fracture classification, current treatment regimens and mortality of distal radius fractures in adults within the context of a large national register study. METHODS: We performed a descriptive study using prospectively registered data from the Swedish fracture register. Included were all non-pathological distal radius fractures registered between January 1st 2015 and December 31st 2017 in patients aged 18 years and above. Nominal variables were presented as proportions of all registered fractures. RESULTS: A total of 23,394 distal radius fractures in 22,962 patients were identified. The mean age was 62.7 ± 17.6 years for all, 65.4 ± 16.0 for women and 53.6 ± 20.0 for men. A simple fall was the most common cause of injury (75%, n = 17,643/23,394). One third (33%, n = 7783/21,723) of all fractures occurred at the patients' residence. 65% (n = 15,178/23,394) of all fractures were classified as extra-articular AO-23-A, 12% (n = 2770/23,394) as partially intra-articular AO-23-B and 23% (n = 5446/23,394) as intra-articular AO-23-C. The primary treatment was non-surgical for 74% (n = 17,358/23,369) and surgical for 26% (n = 6011/23,369) of all fractures. Only 18% of the AO-23-A fractures were treated surgically, compared to 48% of the AO-23-C fractures. The most frequently used surgical method was plate fixation (82%, n = 4954/5972), followed by pin/wire fixation (8.2%, n = 490/5972), external fixation (4.8%, n = 289/5972) and other methods (4.0%, n = 239/5972). The overall 30-day mortality was 0.4% (n = 98/23,394) and the 1-year mortality 2.9% (n = 679/23,394). CONCLUSION: This nation-wide observational study provides comprehensive data on the epidemiology, fracture classification and current treatment regimens of distal radius fractures in a western European setting. The most common patient was an eldery woman who sustained a distal radius fracture through a simple fall in her own residence, and whose fracture was extra-articluar and treated non-surgically.

Ultra-low-dose CT for extremities in an acute setting: initial experience with 203 subjects.

OBJECTIVE: The purpose of this study was to assess if ultra-low-dose CT is a useful clinical alternative to digital radiographs in the evaluation of acute wrist and ankle fractures. MATERIALS AND METHODS: An ultra-low-dose protocol was designed on a 256-slice multi-detector CT. Patients from the emergency department were evaluated prospectively. After initial digital radiographs, an ultra-low-dose CT was performed. Two readers independently analyzed the images. Also, the radiation dose, examination time, and time to preliminary report was compared between digital radiographs and CT. RESULTS: In 207 extremities, digital radiography and ultra-low-dose CT detected 73 and 109 fractures, respectively (p < 0.001). The odds ratio for fracture detection with ultra-low-dose CT vs. digital radiography was 2.0 (95% CI, 1.4-3.0). CT detected additional fracture-related findings in 33 cases (15.9%) and confirmed or ruled out suspected fractures in 19 cases (9.2%). The mean effective dose was comparable between ultra-low-dose CT and digital radiography (0.59 ± 0.33 µSv, 95% CI 0.47-0.59 vs. 0.53 ± 0.43 µSv, 95% CI 0.54-0.64). The mean combined examination time plus time to preliminary report was shorter for ultra-low-dose CT compared to digital radiography (7.6 ± 2.5 min, 95% CI 7.1-8.1 vs. 9.8 ± 4.7 min, 95% CI 8.8-10.7) (p = 0.002). The recommended treatment changed in 34 (16.4%) extremities. CONCLUSIONS: Ultra-low-dose CT is a useful alternative to digital radiography for imaging the peripheral skeleton in the acute setting as it detects significantly more fractures and provides additional clinically important information, at a comparable radiation dose. It also provides faster combined examination and reporting times.

Volume fusion of CT images to measure femoral symmetricity.

PURPOSE: Pre-operative planning is widely used in orthopaedic surgery. In case of trauma with fracture or previous injury with malunion, the contralateral extremity is used as a surrogate for planning with an assumption of symmetry between sides. The aim of this study was to investigate femoral symmetricity in human adults. METHODS: Ten randomly selected lower extremity computerized tomography (CT) images were analyzed for femur symmetry using 3D Trauma and CT motion analysis (CTMA). Mirrored images of the left femur were created using the right as a template. The 3D images from each side were merged, and translational and rotational differences reported. RESULTS: There were no statistically significant differences between mirrored images of the left and right femurs. Differences in rotation and translation of bony segmentation showed a greater variation in internal and external rotation of the distal femur (CI - 0.7° to 4.9°) compared to varus/valgus (CI - 1.3° to 0.8°) or flexion/extension (CI - 0.5° to 0.6°), though none of these differences were significant. CONCLUSION: The left and right femurs of healthy adults are symmetrical. Pre-operative templating relying on the contralateral healthy femur is encouraged.

Surgical repair of acute Achilles tendon ruptures: a follow-up of 639 consecutive cases.

BACKGROUND: Most studies on acute Achilles tendon rupture (AATR) and its treatment contain only a small number of patients, and due to selection criteria, older patients and those with comorbidities are typically excluded. Therefore, little is known about true complication rates in an unselected population reflecting the situation in an ordinary orthopedic department. METHOD: Patient files of 639 consecutive Achilles tendon repairs in 631 patients with AATR between February 1998 and December 2005 were reviewed, and all complications from the day of surgery until December 2011 were identified using the hospital's patient records and the Swedish national registry. RESULTS: Twenty-five (3.9%) re-operations were done, out of which 22 were due to a re-rupture. Fifty-one (8.6%) cases were of deep vein thrombosis (DVT), no difference between patients given versus patients not given thromboprophylaxis. Nineteen (3.0%) cases were of surgical site infection (SSI), all of which resolved upon oral antibiotics. CONCLUSIONS: Surgical repair of acute Achilles tendon rupture was associated with a low risk for re-operations, but the risk for deep vein thrombosis was considerable, despite the use of prophylaxis.

External Fixation Versus Volar Locking Plate for Unstable Dorsally Displaced Distal Radius Fractures-A 3-Year Follow-Up of a Randomized Controlled Study.

PURPOSE: To determine if a volar locking plate (VLP) is superior to external fixation (EF) 3 years after surgery for unstable, dorsally displaced, distal radius fractures caused by low-energy injury in patients 50 to 74 years of age. METHODS: During 2009 to 2013, 140 patients with an unstable dorsally displaced distal radius fracture were randomized to either VLP or EF. One hundred eighteen patients (EF 56, VLP 62) were available for a 3-year follow-up. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 3 years. Secondary outcomes were Patient-Related Wrist Evaluation (PRWE) score, EuroQol-5 Dimensions (EQ-5D) score, range of motion (ROM), grip strength, and radiological signs of osteoarthritis (OA) at 3 years. Moreover, reoperations and minor complications during the first 3 years were recorded. RESULTS: There were no differences regarding DASH, PRWE, EQ-5D, ROM or grip strength. The reoperation rate was 21% (13 of 62) in the VLP group compared with 14% (8 of 56) in the EF group. The OA rate was 42% (25 of 59) in the VLP group compared with 28% (15 of 53) in the EF group. CONCLUSIONS: Three years after surgery for unstable dorsally displaced distal radius fractures, the clinical and radiological results for VLP and EF were comparable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

CCR2 upregulated on peripheral T cells in osteoarthritis but not in bone marrow.

Osteoarthritis (OA) is a condition affecting millions of patients around the world, causing pain and disability and often resulting in joint replacement surgery. The aetiology of OA has long been attributed to mechanical wear mainly due to the increased prevalence of OA in load bearing joints among older patients. However, recent studies reveal a complex molecular disease causality in which inflammation, nutritional deficit and angiogenesis lead to the destruction of the joint structure. The aim of this study was to examine chemokine receptor expression in peripheral blood and bone marrow in OA patients. We devised a protocol for extracting healthy bone marrow from patients undergoing hip arthroplasty due to coxarthrosis. Flow cytometry was used to determine the expression of 18 chemokine receptors on CD4 and CD8 T cells from bone marrow and blood from 7 osteoarthritis patients and peripheral blood from 9 healthy controls. We found a significantly increased fraction of CCR2 expressing CD4 and CD8 T cell in peripheral blood compared to healthy controls. Also, there was a significant decrease in CXCR3 (Th1) (P < 0.01) expressing T cells in peripheral blood from OA patients. Finally, multivariate analysis was used to separate T cell profiles from healthy controls and OA patients and demonstrate that the divergence of chemokine receptor expression occurs in the mature T cell subsets. In conclusion, we find increased CCR2 expression in peripheral blood from OA patients that possibly may be targeted in future clinical studies.

Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register.

BACKGROUND: Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study. METHODS: A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register. RESULTS: A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients' accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h. CONCLUSION: Safety measures to prevent fall at elderly patient's accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study.

BACKGROUND: Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect. METHODS: A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared. RESULTS: There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02). CONCLUSION: We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data.

Background and purpose - Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients' claims of PJI in a nationwide setting Patients and methods - The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients' claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results - We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient's age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation - The incidence of patients' claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation.

Factors affecting mortality and reoperations in high-energy pelvic fractures.

AIM: Factors affecting mortality during the first year following high-energy pelvic fractures has not been reported previously. Nor has surgical complications leading to reoperations been reported in a cohort with only high-energy pelvic trauma patients. OBJECTIVES: The aim of this study was to report and analyse factors affecting outcome, in terms of mortality and reoperations, up to 1 year after the injury in patients with a traumatic pelvic ring injury due to a high-energy trauma. MATERIALS AND METHODS: Data from the SweTrau (Swedish National Trauma Registry) on patients admitted to the Trauma Centre Karolinska in Stockholm, Sweden, were collected. Inclusion criteria were adults (age ≥ 18), trauma with a high-energy mechanism, alive on arrival, Swedish personal identification number, reported pelvic fracture on CT scan. Patient records and radiographies were reviewed. The study period was 2011-2015 with 1-year follow-up time. Univariate and regression analysis on factors affecting mortality was performed. Risk of reoperation was analysed using univariate and case-by-case analysis. RESULTS: We included 385 cases with mean age 47.5 ± 20.6 years (38% females): 317 pelvic fractures, 48 acetabular fractures and 20 combined injuries. Thirty-day mortality was 8% (30/385), and 1-year mortality was 9% (36/385). The main cause of death at 1 year was traumatic brain injury (14/36) followed by high age (> 70) with extensive comorbidities (8/36). Intentional fall from high altitude (OR 6, CI 2-17), GCS < 8 (OR 12, CI 5-33) and age > 70 (OR 17, CI 6-51) were factors predicting mortality. Thirty patients (22%, 30/134) were further reoperated due to hardware-related (n = 18) or non-hardware-related complications (n = 12). Hardware-related complications included: mal-placed screws (n = 7), mal-placed plate (n = 1), implant failure (n = 6), or mechanical irritation from the implant (n = 4). Non-hardware-related reasons for reoperations were: infection (n = 10), skin necrosis (n = 1), or THR due to post-traumatic osteoarthritis (n = 1). CONCLUSION: Non-survivors in our study died mainly because of traumatic brain injury or high age with extensive comorbidities. Most of the mortalities occurred early. Intentional injuries and especially intentional falls from high altitude had high mortality rate. Reoperation frequency was high, and several of the hardware-related complications could potentially have been avoided.

Postoperative periprosthetic fractures in patients with an Exeter stem due to a femoral neck fracture: cumulative incidence and surgical outcome.

PURPOSE: The purpose of this study is to report on the cumulative incidence and the outcome of surgically-treated postoperative PPFs in patients with femoral neck fractures treated with a THA or HA using an Exeter stem. METHODS: A consecutive series of patients operated during 1998-2010 due to a non-pathological femoral neck fracture using an Exeter stem were included in this cohort study. Patients were followed until 2012, or death, in order to obtain information about reoperations due to postoperative PPFs, and subsequent re-operations after surgery due to PPFs. In addition to local audit data the Swedish National Board of Health and Welfare's registry was used to identify patients who had been re-operated upon elsewhere in Sweden. RESULTS: A total of 2,757 patients (median age 82 years, 2,019 females) were identified and included in the study. Of these patients, 63 (2.3%) sustained a postoperative PPF that was treated surgically. The majority of the Vancouver B1 (n = 21/23) and C (n = 14/14) fractures were treated using open reduction and internal fixation (ORIF), whereas most of the B2 (n = 16/25) fractures and the only B3 fracture were treated with stem revision. Three (4.8%) patients were subsequently re-operated upon due to fracture-related complications, all B2 fractures, and were treated with ORIF (n = 2) or stem revision (n = 1). CONCLUSION: The cumulative incidence of surgically treated PPFs was considerable among patients with Exeter stems operated due to a femoral neck fracture. The re-operation rate due to fracture-related complications was highest among patients with B2 fractures.

Prosthetic joint infection following hip fracture and degenerative hip disorder: a cohort study of three thousand, eight hundred and seven consecutive hip arthroplasties with a minimum follow-up of five years.

PURPOSE: Prosthetic joint infections (PJIs) occur on a regular basis and with an increasing incidence. Under reporting of complications to national registries and unreliable ICD-10 coding increases the risk of under estimating the true rate of PJIs after hip arthroplasty. Also, the microbiology and final outcome is less well described, especially for hip-fracture patients operated upon with primary and secondary fracture prostheses. Our aim was to analyse re-operation rate, outcome and microbiology of PJIs following hip arthroplasty in patients operated upon due to hip fractures and degenerative hip disorders. METHODS: This was a single-centre cohort study of 3807 consecutive hip arthroplasties performed between 1996 and 2005. The primary study outcome was to compare the incidence of PJIs. The secondary outcome was to analyse the microbiology and outcome of PJIs. RESULTS: We identified 62 PJIs: seven surgical-site PJIs were found in patients operated upon for a degenerative hip disorder, 22 [hazard ratio (HR) 4.3] were found in patients operated upon for a primary fracture and prosthesis and 25 (HR 6.1) in patients operated upon with a secondary fracture and prosthesis. Outcome treatment was unfavourable for hip fracture patients with a high rate of Girdlestone operation performed (22 of 27). Staphylococcal infections dominated in the fracture group, whereas polybacterial infections were more common in patients with degenerative hip disorder. CONCLUSIONS: Patients with a displaced femoral neck fracture treated primary or secondary with arthroplasties have a greater risk of PJIs and display worse outcomes compared with patients with a total hip replacement due to degenerative hip disorders.