Unchanged incidence but change in treatment trends from 1996 to 2018: 23,718 humeral shaft fractures from the Danish National Patient Registry.

BACKGROUND AND PURPOSE: Humeral shaft fractures (HSF) can be treated surgically or non-surgically. National trends and distributions are sparsely reported. We present the temporal trends in epidemiology of adult HSF in Denmark, with the primary aim of reporting HSF incidences, and the secondary aim of reporting on the primary treatment management. PATIENTS AND METHODS: The diagnosis (International Classification of Diseases Version 10 [ICD-10]: S42.3) and surgical procedure codes for HSF were obtained from the Danish National Patient Registry (DNPR) covering 1996-2018. The diagnosis code for HSF is validated in the DNPR with a positive predictive value of 89%. Patients aged 18 years and above were included. Surgical treatment was defined as a diagnosis of HSF combined with a surgical procedure within 3 weeks of injury. Cases without relevant registered procedures within 3 weeks were defined as nonsurgical treatment cases. RESULTS: 23,718 HSF (62% female) were identified in the DNPR. The overall mean incidence was 25/100,000/year and was stable over 23 years. The population above 50 years accounted for 78% of all HSF. Non-surgical treatment accounted for 87% of treatments and was stable during the study period. Temporal changes were observed regarding surgical procedures; intramedullary nailing decreased from 57% to 26% and plate osteosynthesis increased from 12% to 69%. CONCLUSION: The overall incidence for HSF remained stable from 1996 to 2018. Most cases were females aged 50 years and above. The preferred primary treatment for HSF was non-surgical for all ages. Plate osteosynthesis became more popular than intramedullary nailing over the study period.

Changes in the incidence and treatment of distal radius fractures in adults - a 22-year nationwide register study of 276,145 fractures.

INTRODUCTION: The incidence of distal radius fractures (DRFs) is reported, with conflicting results. To ensure evidence-based practice, the variation in treatment over time should be monitored. Treatment in the elderly population is particularly interesting because newer guidelines find little indication for surgery. Our primary aim was to assess the incidence and treatment of DRFs in the adult population. Secondly, we assessed the treatment stratified on non-elderly (aged 18-64 years) and elderly (aged 65+ years) patients. METHODS: This is a population-based register study comprising all adult patients (i.e. aged over 18 years) with DRFs in the Danish National Patient Register from 1997 to 2018. Data were extracted using the ICD-10 code for DRF (DS52.5), and the incidence was calculated using data from Statistics Denmark. We defined a case as surgically treated if a relevant procedure was performed within three weeks of the DRF diagnosis. Nordic procedure codes were used to define surgical treatments as either plate (KNCJ65), external fixation (KNCJ25), k-wire (KNCJ45), or 'other' (KNCJ35,55,75,85,95). RESULTS: A total of 276,145 fractures were included, with an overall increase in DRFs of 31% during the study period. The overall incidence was 228/100,000/year, which increased by 20% during the study period. The increased incidence was especially notable among women and those aged 50-69 years. Surgical treatment steadily increased from 8% in 1997 to 22% in 2010, thereafter reaching a plateau at 24% in 2018. The surgical rate in the elderly group was as high as in the non-elderly group. In 1997, the treatment distribution of DRFs was as follows: 59% external fixation, 20% plate fixation, and 18% k-wire fixation. From 2007 and onwards, plating was the primary choice of surgery, and in 2018, 96% of patients were treated with a plate. CONCLUSION: We found a 31% increase in DRFs over a 22-year period, mostly driven by an increase in the size of the elderly population. The surgical rate increased markedly even in the elderly group. There is a lack of evidence on how beneficial surgery is for elderly patients, and similar surgical rate between the elderly and non-elderly calls for hospitals to re-evaluate their treatment strategies.

Positive predictive value of humeral fractures in the Danish National Patient Registry.

INTRODUCTION: The purpose of this study was to validate the humeral fracture diagnoses for adults in the Danish National Patient Registry (DNPR). METHODS: This was a population-based validity study, including adult patients (≥ 18 years) with a humeral fracture referred to the emergency department of hospitals in three Danish regions from March 2017 to February 2020. Administrative data were retrieved on 12,912 patients from the databases of the involved hospitals. These databases hold information on discharge and admission diagnoses, which is based on the International Classification of Diseases, tent version. Data of 100 cases were randomly sampled from each of the specific humeral fracture diagnoses (S42.2-S42.9). The positive predictive value (PPV) was estimated for each diagnosis to study the recorded accuracy. Radiographic images from the emergency departments were reviewed and assessed as the gold standard. The PPVs with 95% confidence intervals (CI) were estimated according to the Wilson method. RESULTS: In total, 661 patients were sampled between all available diagnosis codes. Overall, the PPV for humeral fracture was 89.3% (95% CI: 86.6-91.4%). PPVs for the subdivision codes were 91.0% (95% CI: 84.0-95.0%) for proximal humeral fractures, 89.0% (95% CI: 81.0-94.0%) for humeral diaphyseal fractures and 78.0% (95% CI: 68.9-84.9%) for distal humeral fractures. CONCLUSION: The validity of the humeral fracture diagnosis and the classifications of proximal and diaphyseal fractures in the DNPR is high, and the DNPR may therefore be used in registry research. Diagnosis of distal humeral fractures has a lower validity and should be used with caution. FUNDING: none. TRIAL REGISTRATION: not relevant.

Exploring patient experiences after treatment of humeral shaft fractures: A qualitative study.

INTRODUCTION: Humeral shaft fracture treatment can induce serious morbidities, and it is unclear how these morbidities impact patients. To gain in-depth knowledge, we explored how patients experience humeral shaft fractures and the subsequent treatment course. METHOD: A qualitative study was performed using semi-structured individual interviews. A purposive sampling approach was conducted to recruit patients with traumatic isolated humeral shaft fractures; the patients' ages, genders, primary treatments, and complications varied. Data saturation was met after the data of 12 patients were analyzed using Malterud Systematic Text Condensation. RESULTS: Eight women and four men with a median age of 48.5 years (range: 22-83 years) were interviewed. The median time from injury to interview was 12.5 months (range: 8-18 months). Ten out of twelve patients were treated non-surgically; of those ten, four patients experienced major complications from the primary treatment. During the analysis, five overarching themes appeared: expectations, physical changes, support and independence, psychological impact, and the specific treatment and recovery. CONCLUSION: First, patients with humeral shaft fractures expressed frustration with treatment in the emergency department. Second, gross fracture movement and pain were central symptoms that led to the loss of basic capabilities. Third, patient preferences were included in the treatment decision-making process and could change throughout the treatment course. Fourth, patients required massive support to perform basic activities of daily living.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial.

BACKGROUND: The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures. METHODS: A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality. DISCUSSION: The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery. TRIAL REGISTRATION: Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

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.

Long-term Survival After Surgical Treatment of Spinal Metastasis - The Predictive Role of Sex.

BACKGROUND/AIM: An increasing number of patients undergo surgical treatment for metastatic spinal cord compression (MSCC). However, the possible role of sex as an independent predictor of long-term survival has not been studied. This study aimed to examine whether sex is associated with long-term survival after surgical treatment in patients with MSCC. PATIENTS AND METHODS: A total of 110 patients were operated on for MSCC from 2005 through 2006. The relation between sex and overall survival was investigated. The follow-up period was 10 years. RESULTS: Survival time was significantly longer for women compared to men (mean±SD: 29±5.2 vs. 14±3.6 month (p=0.01). With adjusted analysis, this difference remained statistically significant. After adjusting for specific primary tumor type and time since surgery, the hazard-ratio of 10-year survival for men compared to women was 1.47 (95% confidence intervaI=1.01-2.18, p=0.048). CONCLUSION: These findings indicate that sex is associated with long-term survival in patients treated for MSCC.

Hip malformation is a very common finding in young patients scheduled for total hip arthroplasty.

INTRODUCTION: In Denmark, 20% of all registered total hip arthroplasties (THA) from 1995 to 2014 has been patients younger than 60 years with primary idiopathic osteoarthritis (OA). It is speculated that hip malformations may be a major contributor to early OA development. It has been shown that hip malformation may compromise implant position and, therefore, identifying and knowing the incidence of malformations is important. Our aim was to assess the prevalence and type of hip malformations in a cohort of younger patients undergoing THA. MATERIALS AND METHODS: In this prospective two center cohort study, 95 consecutive patients (106 hips) met the inclusion criteria. One observer performed radiographic measurements for malformations and radiographic OA. Inter- and intraobserver variability was assessed. RESULTS: From 95 patients (male n = 52 and female n = 43) age ranged from 35 to 59 years and prevalences of hip malformations were; CAM-deformity 50.9 and 25.5%, coxa profunda 33 and 27.4%, acetabular retroversion 33 and 29.2%, and acetabular dysplasia 10.4 and 3.8%. All patients showed minimum of one malformation. Prevalences of Tönnis grade 0-1 were 22.6% and 2-3 were 77.4%. CONCLUSION: All patients showed malformations, especially high prevalences were found for CAM-deformity, coxa profunda and acetabular retroversion. Identifying these malformations is fairly simple and recognizing the high prevalence may help surgeons avoid pitfalls during implant positioning in THA surgery. Further, focus on hip malformations may facilitate correct referral to joint-preserving surgery before OA develops.