Epidemiology and changed surgical treatment methods for fractures of the distal radius: a registry analysis of 42,583 patients in Stockholm County, Sweden, 2004­2010.

BACKGROUND AND PURPOSE: The incidence of fractures of the distal radius may have changed over the last decade, and operative treatment has been commoner during that time. We investigated the incidence of fractures of the distal radius and changing trends in surgical treatment during the period 2004-2010. PATIENTS AND METHODS: Registry data on 42,583 patients with a fracture of the distal radius from 2004 to 2010 were evaluated regarding diagnosis, age, sex, and surgical treatment. RESULTS: The crude incidence rate was 31 per 10(4) person-years with a bimodal distribution. After the age of 45 years, the incidence rate in women increased rapidly and leveled off first at a very high age. The incidence rate in postmenopausal women was lower than previously reported. In men, the incidence was low and it increased slowly until the age of 80 years, when it amounted to 31 per 10(4) person-years. The number of surgical procedures increased by more than 40% despite the fact that there was reduced incidence during the study period. In patients ≥ 18 years of age, the proportion of fractures treated with plating increased from 16% to 70% while the use of external fixation decreased by about the same amount. INTERPRETATION: The incidence rate of distal radius fractures in postmenopausal women appears to have decreased over the last few decades. There has been a shift in surgical treatment from external fixation to open reduction and plating.

Wrist function recovers more rapidly after volar locked plating than after external fixation but the outcomes are similar after 1 year.

BACKGROUND AND PURPOSE: Promising results have been reported after volar locked plating of unstable dorsally displaced distal radius fractures. We investigated whether volar locked plating results in better patient-perceived, objective functional and radiographic outcomes compared to the less invasive external fixation. PATIENTS AND METHODS: 63 patients under 70 years of age, with an unstable extra-articular or non-comminuted intra-articular dorsally displaced distal radius fracture, were randomized to volar locked plating (n = 33) or bridging external fixation. Patient-perceived outcome was assessed with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) questionnaire. RESULTS: At 3 and 6 months, the volar plate group had better DASH and PRWE scores but at 12 months the scores were similar. Objective function, measured as grip strength and range of movement, was superior in the volar plate group but the differences diminished and were small at 12 months. Axial length and volar tilt were retained slightly better in the volar plate group. INTERPRETATION: Volar plate fixation is more advantageous than external fixation, in the early rehabilitation period.

Large femoral bone loss after hip revision using the uncemented proximally porous-coated Bi-Metric prosthesis: 22 hips followed for a mean of 6 years.

BACKGROUND AND PURPOSE: Periprosthetic bone loss after uncemented femoral hip revision is a matter of concern. We have used a proximally porous- and hydroxyapatite-coated prosthesis (Bi-Metric) in revision since 1989 and now we report the bone changes. This prosthesis is intended to distribute the forces more evenly and to avoid proximal femoral unloading. METHODS: 22 patients were unilaterally reoperated because of aseptic loosening. Only patients with a healthy contralateral hip were included. Mean age at revision was 69 (55-80) years. Bone defects were graded by Gustilo-Pasternak and Endo-Klinik classifications. Clinical assessment was performed with Harris hip score. We used radiographs and dual-energy X-ray absorptiometry to evaluate migration, femoral remodeling, and bone mineral density after 72 (30-158) months. RESULTS: The mean Harris hip score was 74 (30-100) points at follow-up. Mild thigh discomfort was present in 1 patient and moderate thigh pain in 3 patients. There was no loosening or subsidence. Osteolysis seen at revision had diminished in 19 of the 22 hips at follow-up. We noted a large reduction in bone mineral density. It was most pronounced in Gruen regions 1, 2, 6, and 7. INTERPRETATION: Revision with this stem is a reliable procedure; however, we noted a large degree of proximal bone loss that could lead to later mechanical complications or fractures.

Evaluation of a Swedish version of the patient-rated wrist evaluation outcome questionnaire: good responsiveness, validity, and reliability, in 99 patients recovering from a fracture of the distal radius.

The patient-rated wrist evaluation (PRWE) form is an established outcome questionnaire designed to measure wrist pain and disabilities in activities of daily living. We translated and validated this score for use in Sweden. The original PRWE score was translated forwards and backwards, and then the responsiveness, validity, and reliability of the Swedish version were tested in 99 patients who were recovering from a fracture of the distal radius. The patients completed the PRWE questionnaire 7 weeks and 4 to 6 months after the injury. Responsiveness was assessed by Standard Response Mean and Effect Size. Content validity was evaluated by examining the proportion of best and worse possible scores. Construct validity was assessed by comparing scores twice after the injury and by comparing patients with fractures of different severity. Criterion validity was evaluated by correlating the PRWE with another upper extremity score: the disability of the arm, shoulder, and hand (DASH) score. Reliability was evaluated with a test-retest and by internal consistency. Responsiveness was excellent (SRM = 1.4-1.7, ES = 1.3). Five patients reported the best possible result after 4 to 6 months but none at 7 weeks, and no patient reported the worst score at any time. The PRWE score corresponded well with improvement and showed good correlation with severity of fracture. The PRWE showed a strong correlation with DASH score (Spearman's rank coefficient = 0.86). Intraobserver reliability of the test-retest and internal consistency was good (Kendall W coefficient = 0.79, Spearman's rank coefficient = 0.99, Cronbach's alpha = 0.94-0.97). We found this Swedish version of the PRWE to be responsive, valid, and reliable for evaluating the patient-rated outcome after a fracture of the distal radius.

Good results with an uncemented proximally HA-coated stem in hip revision surgery: 62 hips followed for 2-13 years.

BACKGROUND AND PURPOSE: Proximal bone loss due to stress-shielding is a matter of concern after uncemented femoral hip revision. We have used short, proximally hydroxyapatite-coated prostheses in revision since 1989, and we now report the results. METHODS: 60 patients (62 hips) were revised because of aseptic loosening. Bone defects prior to revision were mostly of type II according to the Gustilo-Pasternak and Endo-Klinik classifications. Follow-up time was 73 (24-161) months. 9 patients had died before follow-up; 8 of these still had the stem in place. Clinical assessment was performed with the Harris hip score. Radiographs were evaluated for bone defects at revision, postoperative stem fixation, and periprosthetic bone remodeling. RESULTS: Mean Harris hip score was 75 (30-100) points. There was no stem loosening or progressive subsidence. 8 patients had mild to moderate thigh pain. Osteolysis, present at revision, had diminished, partially or completely, in four-fifths of the hips at follow-up. 4 hips had required re-revision due to fracture or dislocation. The 6-year prosthesis survival rate was 95% (95% CI: 0.83-0.98). INTERPRETATION: Uncemented revision with a short, proximally hydroxyapatite-coated prosthesis is a reliable procedure with encouraging results in the medium term if bone defects at revision are moderate.

Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years.

This study investigated 82 patients who underwent primary hemiarthroplasty for a severely displaced proximal humerus fracture at Danderyd Hospital between 1989 and 2002. According to the Neer classification system, fractures were 2-part in 2, 3-part in 20, and 4-part in 60. The prostheses used were 12 Neer-II, 39 Global, and 31 Bigliani-Flatow. Follow-up time averaged 4.4 years (range, 1-14 years). Twenty-two patients died, 9 were contacted by phone, and 5 were lost to follow-up. Forty-six patients underwent clinical examination, including the Constant score (CS) and radiographic examination. Mean CS for all patients was 42 of 100 points (range, 11-83 points). Radiologic evaluation revealed that 24 prostheses had migrated superiorly; this finding decreased the CS significantly. Ectopic bone developed in 25 patients, 16 had glenoid erosion, and 5 had displaced tuberosities; no correlation was found with the CS. Hemiarthroplasty usually prevented shoulder pain, but most patients had moderate function and poor strength. The reduced function appeared to be related to a lack of rotator cuff integrity.

Patient-perceived outcome after displaced distal radius fractures. A comparison between radiological parameters, objective physical variables, and the DASH score.

Outcome after distal radius fractures has traditionally been measured by radiological parameters and objective physical variables. To what extent these measurements reflect outcome as perceived by the patient has been questioned. We evaluated the association between radiological position, objective physical result (grip strength and range of movement), and the patient-perceived outcome, measured with the Disabilities of the Arm, Shoulder, and Hand outcome (DASH) score, in 78 patients with a healed unilateral distal radius fracture treated with either closed reduction and plaster splint or external fixation. Fifty-seven females and 21 males (median age 59 yr; range, 22-95) were retrospectively assessed after a mean of 22 months and the mean DASH score was 13 points. Linear correlations between final radiological and objective physical measurements and DASH score were weak or insignificant. However, radial shortening > or = 2mm, dorsal angulation >15 degrees, and radial angulation >10 degrees were each significantly associated with a poorer DASH score. Reduced grip strength, extension, and ulnar deviation correlated with a poorer DASH score. In conclusion, we found that better final radiological and objective physical results were associated with a better patient-perceived outcome, as measured by the DASH score, in this patient group.

Periprosthetic proximal bone loss after uncemented hip arthroplasty is related to stem size: DXA measurements in 138 patients followed for 2-7 years.

BACKGROUND: Periprosthetic bone loss occurs around uncemented femoral stems and may be influenced by the stem size. PATIENTS AND METHODS: We studied 138 consecutive patients, 3 (2-7) years on average after a total hip arthroplasty operation (THA) for unilateral osteoarthritis with the Bi-Metric uncemented femoral stem. We analyzed Harris hip score and bone mineral density. RESULTS: The mean Harris hip score was 97 at follow-up. Bone mineral density decreased proximally by 19% in both Gruen zones 1 and 7. Bone loss in zones 1, 2, 6, and 7 was significantly associated with stem size. Distally, a small gain in bone mass was found in zones 3 and 5 for medium femoral sizes. INTERPRETATION: We found a marked proximal BMD loss, especially for the larger stems, which may be specific for this particular implant. Long-term studies should reveal whether this proximal bone loss will affect the longevity of the THA.

Continuous bone loss around a tapered uncemented femoral stem: a long-term evaluation with DEXA.

BACKGROUND: Periprosthetic bone loss is a well-documented phenomenon after uncemented total hip arthroplasty (THA); however, little is known about how bone mineral density (BMD) changes after 2 years. PATIENTS AND METHODS: 14 patients with hip arthrosis (group A) were operated with a proximally porous- and hydroxyapatite-coated stem and followed for 10 years with DEXA, radiographs and Harris hip score (HHS). Another group of 14 patients (group B) was evaluated at 6 and 14 years using the same prosthesis and protocol. RESULTS: No stem was revised and all stems were well-Fixed. At final follow-up, HHS was 97 points in group A after 10 years and 94 points in group B after 14 years. Bone mineral changes in group A were greatest in Gruen zones 1 and 7, where the losses were 31% and 26%, respectively, after 2 years on the operated side. The decrease in BMD continued after 2 years and in Gruen zone 7 it was faster than the rate of bone loss on the control side. In group B, the annual change in BMD on the operated side was not significantly different from the bone loss in group A. INTERPRETATION: Up to 14 years after implantation of a tapered uncemented stem, the BMD in the calcar region continues to decrease faster than would be expected from normal ageing.