20-year trends of distal femoral, patellar, and proximal tibial fractures: a Danish nationwide cohort study of 60,823 patients.

Background and purpose - Knee fracture treatment burden remains unknown, impeding proper use of hospital resources. We examined 20-year trends in incidence rates (IRs) and patient-, fracture-, and treatment-related characteristics of knee fracture patients.Patients and methods - This nationwide cohort study of prospectively collected data including patients with distal femoral, patellar, and proximal tibial fractures from the Danish National Patient Registry during 1998-2017, assesses IRs of knee fractures (per 105 inhabitants) as well as patient-, fracture-, and treatment-related characteristics of knee fracture patients.Results - During 1998-2017, 60,823 patients (median age 55; 57% female) sustained 74,106 knee fractures. 74% of the study population had a Charlson Comorbidity Index (CCI) of 0 and 18% a CCI of ≥ 2. 51% were proximal tibial fractures, 31% patellar fractures, and 18% distal femoral fractures. At the time of knee fracture, 20% patients had concomitant near-knee fractures (femur/tibia/fibula shaft/hip/ankle), 13% concomitant fractures (pelvic/spine/thorax/upper extremities), 5% osteoporosis, and 4% primary knee osteoarthritis. Over 1/3 knee fractures were surgically treated and of these 86% were open-reduction internal fixations, 9% external fixations, and 5% knee arthroplasties. The most common surgery type was proximal tibia plating (n = 4,868; 60% female). Knee fracture IR increased 12% to 70, females aged > 51 had the highest knee fracture IR, proximal tibial fracture had the highest knee fracture type IR (32) and surgically treated knee fracture IR increased 35% to 23.Interpretation - Knee fracture IRs, especially of surgically treated knee fractures, are increasing and proximal tibial fracture has the highest knee fracture type IR. Females aged > 51 and patients with comorbidity are associated with knee fracture, proximal tibial fracture, proximal tibial fracture surgery, and posttraumatic knee arthroplasty.

Completeness and validity of the Danish fracture database.

OBJECTIVE: To calculate completeness of the Danish Fracture Database (DFDB) overall and stratified by hospital volume and to calculate the validity of independently assessed variables in the DFDB. STUDY DESIGN AND SETTING: In this completeness and validation study, cases registered in the DFDB with fracture-related surgery in 2016 were retrospectively reviewed. All cases had undergone fracture-related surgery at a Danish hospital reporting to the DFDB in 2016. The Danish health care system is fully tax-funded providing equal and free access to all residents. Completeness was calculated as sensitivity and validity was calculated as positive predictive values (PPVs). RESULTS: OVERALL COMPLETENESS WAS 55.4% (95% CI: : 54.7-56.0). For small-volume hospitals it was 60% (95% CI: 58.9-61.1), and for large-volume hospitals, it was 52.9% (95% CI: 52.0-53.7). The PPV for variables of interest ranged from 81% to 100%. The PPV of key variables was 98% (95% CI: 95-98) for operated side, 98% (95% CI: 96-98) for date of surgery, and 98% (95% CI: 98-100) for surgery type. CONCLUSION: We found low completeness of data reported to the DFDB in 2016; however, in the same period, the validity of data in the DFDB was high.

Surgical treatment of displaced isolated lateral malleolar fractures: incidence of adverse events requiring revision: a retrospective cohort study.

BACKGROUND: Recent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of "potentially stable" displaced ILMFs before non-operative treatment became standard care in our department. MATERIALS AND METHODS: To identify patients with "potentially stable" ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System. RESULTS: The study population comprised 108 patients with "potentially stable" displaced ILMFs; 4 patients (3.7% [95% CI (0.1-7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort. CONCLUSIONS: Surgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures.

Suture tension band fixation vs. metallic tension band wiring for patella fractures - A biomechanical study on 19 human cadaveric patellae.

PURPOSE: Traditional tension band fixation of patella fracture is associated with high reoperation rates. The purpose of the study was to assess strength of fixation in patella fractures treated with either a non-metallic all suture-based technique or traditional metallic tension band wiring. METHODS: Ten paired human cadaveric specimens were included. A transverse fracture was created, reduced and fixated with a non-metallic or metallic approach. Non-metallic fixation was done according to a previously published technique, metallic fixation was done according to AO description. Specimens were fixed in 90° of flexion and underwent 200 cycles of loading by pulling the Quadriceps tendon to 300 Newton. Fracture displacement was optically monitored. Primary outcome was fracture displacement after 200 cycles compared to the first cycle. Subsequently, load-to-failure was assessed by a monotonic pull to 1000 N. RESULTS: For cyclic loading analysis, one specimen from each group was excluded due to machine synchronization, resulting in a total population of 18 specimens. Median (min-max) fracture displacement was 0.65 mm (0.06-1.3) in the non-metallic group and 0.68 mm (0-1.23), (p=0.931) in the metallic group. No difference in displacement was found between the two groups in the repeated measures analysis of variance (p=0.5524). For load-to-failure analysis one specimen was excluded due to machine synchronization, resulting a total population of 19 specimens. 2/9 specimens failed in the non-metallic group (at 979 and 635 N) and 2/10 failed in the metallic group (745 and 654 N). CONCLUSION: Non-metallic technique is a biomechanically viable alternative to traditional tension band fixation and it can hopefully lead to fewer implant-related complications.

The Noergaard technique is a non-traumatic method for reduction of anterior shoulder dislocation.

INTRODUCTION: In this article, we describe the Noergaard technique for reduction of anterior shoulder dislocation. This is an atraumatic reduction method proven successful through several years of practice. We describe and evaluate the results of this technique through a retrospective analysis of patients admitted and treated for anterior shoulder dislocation at the emergency department (ED) of Hvidovre Hospital, Denmark, in a one-year period. METHODS: We reviewed the charts of all patients admitted with anterior shoulder dislocation (n = 151) at the ED. In the Noergaard technique, the patient is placed standing, bent over forwards in front of the rail on a hospital bed, resting the forehead on the back of the non-affected forearm, which is placed on the rail. The affected arm should now be relaxed and stretched, hanging straight down towards the floor. The patient is then instructed to relax as much as possible and make pendular and circular motions with the affected arm hanging down. RESULTS: Reduction was primarily attempted in 67 patients using the Noergaard technique. Successful reduction was achieved in a total of 52 patients (77%). CONCLUSIONS: The Noergaard technique seems to be a safe and atraumatic reduction technique that involves no physical manipulation of the affected limb. Based on our results and experience, we recommend the use of this technique as first line of treatment in anterior shoulder dislocations. FUNDING: none. TRIAL REGISTRATION: The study was registered with www.clinicaltrials.gov (NCT03649373).

Knee pain and associated complications after intramedullary nailing of tibial shaft fracture.

INTRODUCTION: The treatment of choice for unstable diaphyseal fractures in the tibia is reamed insertion of an intramedullary nail (IMN). The most common complication to this treatment is chronic knee pain with reported rates ranging from 10% to 87% with a mean of 47.4% in meta-analyses. METHODS: This study evaluates the long-term outcome after IMN insertion in adult patients with a tibial shaft fracture using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The study includes patients operated on one of five Danish hospitals in a five-year period. The patients received a KOOS questionnaire with questions regarding knee-specific symptoms, stiffness, pain, function and quality of life. Data were subsequently compared to those of a reference population. RESULTS: A total of 391 patients were enrolled from the trauma centre's database search. 55 patients did not meet the inclusion criteria. Questionnaires were sent out to 336 patients and 223 (66%) responded. Mean age was 47.9 years at the time of surgery; 63% were men. The follow-up time ranged from 1.7 to 6.7 years. CONCLUSIONS: With a follow-up time of more than six years after receiving an IMN, patients in this study experienced more knee-specific symptoms, pain, limitations in sports and daily living than a reference population who had not undergone surgery. The study population also reported poorer quality of life outcomes than the reference population. FUNDING: none. TRIAL REGISTRATION: Approved by the Danish Data Protection Agency. Clinical trials: NCT03649360.

[Treatment of ankle fractures].

Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the Lauge-Hansen- and the Weber classifications, have proven inadequate, when it comes to deciding, whether treatment should be surgical or conservative. About ten years ago, a stability-based classification was proposed in view of the fact, that the stabilisation of osteosynthesis depends on the stability of the ankle joint. The literature shows excellent long-term results for conservatively treated stable ankle joint fractures.

[Patients in need for major lower extremity amputations are a challenge]. / Den amputationstruede patient er en udfordring for sundhedsvæsenet.

Major lower extremity amputations based on end-stage chronic leg ischaemia or diabetic ulcers with infection are relatively common orthopaedic procedures. Patients are usually evaluated for the possibility of lower extremity revascularisation. Those who are not fit for vascular surgery are transferred to an orthopaedic department for amputation. These patients are a big challenge as they are by definition multi-morbid individuals, who have to undergo major surgery. The high mortality rate in this population warrants new approaches, including optimised multidisciplinary regimes.

[Overlooked spin-out phenomenon as the course of pain in a patient with a mobile-bearing total knee arthroplasty]. / Overset spin-out-fænomen som årsag til kroniske smerter hos patient med totalknæalloplastik.

We present a case of a 66-year-old woman who had a total knee arthroplasty. Shortly after surgery a 90° rotation of her polyethylene liner took place. The complication was undiagnosed for 1.5 years. To know this problem and be able to diagnose it is crucial for doctors, who come in contact with patients who have had a total knee arthroplasty.

[Tranexamic acid reduces blood loss after major elective orthopaedic operations]. / Tranexamsyre reducerer blodtabet efter større elektive ortopædkirurgiske operationer.

Anaemia in surgical patients has been proven to increase morbidity and mortality. Due to the risk of adverse effects and the cost of blood transfusions it is important to reduce the need for transfusions by pre- and intra-operative interventions. Tranexamic acid has long been used in orthopaedic surgery as an antifibrinolytic agent. Several studies within the orthopaedic fields have underlined the effect of the drug in reducing blood loss and need for transfusions. However, more studies are needed to examine the optimal dosage and administration along with the risks associated with the drug.

[Promising conservative treatment using dynamic mobilisation after Achilles tendon rupture]. / Lovende resultater ved konservativ behandling med dynamisk mobilisering efter akillesseneruptur.

There is no consensus regarding the optimal treatment of acute Achilles tendon ruptures. This review of the literature on the subject shows a significantly higher rate of reruptures (RR) in the conservatively treated group compared to the surgically treated group when the foot is immobilised in the aftertreatment. Recent studies that used early dynamic mobilisation in the conservatively treated group did not show this difference in the RR rate. The latest literature on the subject indicates that non-operative treatment, followed by dynamic aftertreatment, results in the lowest complication rate and a good functional outcome.