Promoting cemented fixation of the femoral stem in elderly female hip arthroplasty patients and elderly hip fracture patients: a retrospective cohort study from the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register.

BACKGROUND AND PURPOSE: Uncemented stems increase the risk of revision in elderly patients. In 2018, we initiated a national quality improvement project aiming to increase the proportion of cemented stems in elderly female total hip arthroplasty (THA) and hip fracture hemiarthroplasty (HA) patients. We aimed to evaluate the association of this project on the frequency of cemented stems and the risk of secondary procedures in the targeted population. METHODS: 10,815 THAs in female patients ≥ 75 years in the Norwegian Arthroplasty Register and 19,017 HAs in hip fracture patients ≥ 70 years in the Norwegian Hip Fracture Register performed in 2015-2017 and 2019-2021 at all Norwegian hospitals were included in this retrospective cohort study. The quality improvement project was implemented at 19 hospitals (8,443 patients). 1-year revision risk (THAs) and reoperation risk (HAs) were calculated for uncemented and cemented stems by Kaplan-Meier and Cox adjusted hazard rate ratios (aHRRs) with all-cause revision/reoperation as main endpoint. RESULTS: The use of cemented stem fixation in the targeted population increased from 26% to 80% for THAs and from 27% to 91% for HAs. For THAs, the 1-year revision rate decreased from 3.7% in 2015-2017 to 2.1% in 2019-2021 (aHRR 0.7, 95% confidence interval [CI] 0.5-0.9) at the intervention hospitals. For HAs, the reoperation rate decreased from 5.9% in 2015-2017 to 3.3% in 2019-2021 (aHRR 0.6, CI 0.4-0.8) at the intervention hospitals. CONCLUSION: The quality improvement project resulted in a significant increase in the proportion of cemented stems and reduced risk of secondary procedures for both THAs and HAs.

Poor survivorship of total ankle replacements. 1368 cases from the period 1994-2021 in the Norwegian arthroplasty register.

BACKGROUND AND PURPOSE: The aim of the study was to present the performance of total ankle replacements (TAR) in a national register. METHODS: All surgeons in the country report to the Norwegian Arthroplasty Register. The completeness of primary TARs in NAR was 79-90% in the years 2017-2020. Cox regression analyses and the Kaplan-Meier method were used to study implant survival and revision risk. RESULTS: 1368 primary TAR´s were implanted in 1266 patients during the period 1994-2021. The last few years saw a marked decrease in the incidence of TARs. The overall survival at 5 years was 81.1% (80.9-81.3) and 69.3% (66.4-72.2) at 10 years. Higher age was strongly associated with better survival. Current prosthesis designs had a better survival than earlier designs ((HRR 0.7, 95% CI 0.6-0.9) CONCLUSION: Revision rates were high in our registry, but current implants had better survival. Younger age increased the risk of revision. LEVEL OF EVIDENCE: Level II: prospective cohort study.

The unmet need for treatment of children with musculoskeletal impairment in Malawi.

BACKGROUND: More than a billion people globally are living with disability and the prevalence is likely to increase rapidly in the coming years in low- and middle-income countries (LMICs). The vast majority of those living with disability are children residing in LMICs. There is very little reliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and even less is available for Malawi. Previous studies in Malawi on childhood disability and the impact of musculoskeletal impairment (MSI) on the lives of children have been done but on a small scale and have not used disability measurement tools designed for children. Therefore in this study, we aimed to estimate the MSI prevalence, causes, and the treatment need among children aged 16 years or less in Malawi. METHODS: This study was carried out as a national cross sectional survey. Clusters were selected across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the national distribution of the population. Clusters were distributed around all 27-mainland districts of Malawi. Population of Malawi was 18.3 million from 2018 estimates, based on age categories we estimated that about 8.9 million were 16 years and younger. MSI diagnosis from our randomized sample was extrapolated to the population of Malawi, confidence limits was calculated using normal approximation. RESULTS: Of 3792 children aged 16 or less who were enumerated, 3648 (96.2%) were examined and 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7-7.3). Extrapolated to the Malawian population this means as many as 576,000 (95% CI 505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were due to congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% were acquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6000-33,000) children in need of orthopaedic surgery. Low parents' educational level was one factor associated with an increased risk of MSI. CONCLUSION: This survey has uncovered a large burden of MSI among children aged 16 and under in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended, revealing a need to scale up both P&O services, physical & occupational therapy, and surgical services in the country.

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients.

BACKGROUND: The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery. METHODS: Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression. RESULTS: The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7-6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6-29). CONCLUSION: An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

Cemented or Uncemented Hemiarthroplasty for Femoral Neck Fracture? Data from the Norwegian Hip Fracture Register.

BACKGROUND: A displaced femoral neck fracture in patients older than 70 years is a serious injury that influences the patient's quality of life and can cause serious complications or death. Previous national guidelines and a Cochrane review have recommended cemented fixation for arthroplasty to treat hip fractures in older patients, but data suggest that these guidelines are inconsistently followed in many parts of the world; the effects of that must be better characterized. QUESTIONS/PURPOSES: The purpose of this study was to evaluate a large group of patients in the Norwegian Hip Fracture Register to investigate whether the fixation method in hemiarthroplasty is associated with (1) the risk of reoperation; (2) the mortality rate; and (3) patient-reported outcome measures (PROMs). METHODS: Longitudinally maintained registry data from the Norwegian Hip Fracture Register with high completeness (93%) and near 100% followup of deaths were used for this report. From 2005 to 2017, 104,993 hip fractures were registered in the Norwegian Hip Fracture Register. Fractures other than intracapsular femoral neck fractures and operative methods other than bipolar hemiarthroplasty, such as osteosynthesis or THA, were excluded. The selection bias risk on using cemented or uncemented hemiarthroplasty is small in Norway because the decision is usually regulated by tender processes at each hospital and not by surgeon. A total of 7539 uncemented hemiarthroplasties (70% women, mean age, 84 years [SD 6] years) and 22,639 cemented hemiarthroplasties (72% women, mean age, 84 years [SD 6] years) were eligible for analysis. Hazard risk ratio (HRR) on reoperation and mortality was calculated in a Cox regression model adjusted for age, sex, comorbidities (according to the American Society of Anesthesiologists classification), cognitive function, surgical approach, and duration of surgery. At 12 months postoperatively, 65% of patients answered questionnaires regarding pain and quality of life, the results of which were compared between the fixation groups. RESULTS: A higher overall risk of reoperation for any reason was found after uncemented hemiarthroplasty (HRR, 1.5; 95% CI, 1.4-1.7; p < 0.001) than after cemented hemiarthroplasty. When assessing reoperations for specific causes, higher risks of reoperation because of periprosthetic fracture (HRR, 5.1; 95% CI, 3.5-7.5; p < 0.001) and infection (HRR, 1.2; 95% CI, 1.0-1.5; p = 0.037) were found for uncemented hemiarthroplasty than for cemented procedures. No differences were found in the overall mortality rate after 1 year (HRR, 1.0; 95% CI, 0.9-1.0; p = 0.12). Hemiarthroplasty fixation type was not associated with differences in patients' pain (19 versus 20 for uncemented and cemented hemiarthroplasties respectively, p = 0.052) or quality of life (EuroQol [EQ]-VAS score 64 versus 64, p = 0.43, EQ5D index score 0.64 versus 0.63, p = 0.061) 1 year after surgery. CONCLUSIONS: Our study found that the fixation method was not associated with differences in pain, quality of life, or the 1-year mortality rate after hemiarthroplasty. Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures because there is an increased reoperation risk.Level of Evidence Level III, therapeutic study.

A prospective study on cancer risk after total hip replacements for 41,402 patients linked to the Cancer registry of Norway.

BACKGROUND: Concerns have been raised that implants used in total hip replacements (THR) could lead to increased cancer risk. Several different materials, metals and fixation techniques are used in joint prostheses and different types of articulation can cause an increased invasion of particles or ions into the human body. METHODS: Patients with THR registered in the Norwegian Arthroplasty Register during 1987-2009 were linked to the Cancer registry of Norway. Patients with THR due to osteoarthritis, under the age of 75 at time of surgery, were included. Standardized incidence ratios (SIR) were applied to compare cancer risk for THR patients to the general population. Types of THR were divided into cemented (both components), uncemented (both components), and hybrid (cemented femoral and uncemented acetabular components). To account for selection mechanisms, time dependent covariates were applied in Cox-regression, adjusting for cancer risk the first 10 years after surgery. The analyses were adjusted for age, gender and if the patient had additional THR-surgery in the same or the opposite hip. The study follows the STROBE guidelines. RESULTS: Comparing patients with THR to the general population in Norway we found no differences in cancer risk. The overall SIR for the THR-patients after 10 years follow-up was 1.02 (95% CI: 0.97-1.07). For cemented THR, the SIR after 10 years follow-up was 0.99 (95% CI: 0.94-1.05), for uncemented, 1.16 (95% CI: 1.02-1.30), and for hybrid 1.12 (95% CI: 0.91-1.33). Adjusted Cox analyses showed that patients with uncemented THRs had an elevated risk for cancer (hazard ratio: HR = 1.24, 95% CI: 1.05-1.46, p = 0.009) when compared to patients with cemented THRs after 10 years follow-up. Stratified by gender the increased risk was only present for men. The risk for patients with hybrid THRs was not significantly increased (HR = 1.07, 95% CI: 0.85-1.35, p = 0.55) compared to patients with cemented THRs. CONCLUSIONS: THR patients had no increased risk for cancer compared to the general population. We found, however, that receiving an uncemented THR was associated with a small increased risk for cancer compared to cemented THR in males, but that this may be prone to unmeasured confounding.

Is there a weekend effect after hip fracture surgery? A study of 74,410 hip fractures reported to the Norwegian Hip Fracture Register.

Background and purpose - The term "weekend effect" describes differences in outcomes between patients treated at weekends compared with weekdays. We investigated whether there is a weekend effect for the risk of reoperation and mortality after hip fracture surgery at Norwegian hospitals.Patients and methods - We included data from 76,410 hip fractures in patients 60 years and older reported to the Norwegian Hip Fracture Register (NHFR) between 2005 and 2017. Cox survival analyses with adjustments for age, sex, ASA class, type of fracture, operating method, and waiting time from fracture to surgery were used to calculate the risk of reoperation and death after surgeries performed at weekends compared with surgeries performed on weekdays.Results - The mean age for all patients was 82 years, and 71% were female. 73% of fractures occurred on weekdays (Monday to Friday) and 27% during weekends (Saturday and Sunday). 71% of fractures were operated on a weekday and 29% at a weekend. Slightly increased mortality was observed during the 2 first months after weekend admission with hip fracture (HR 1.08; 95% CI 1.03-1.14). This did not continue in subsequent months, but the initial effect of weekend presentation was still apparent at 1-year follow-up. Further, there was no difference in mortality between patients who were operated at a weekend and patients operated on a weekday. Neither were there any differences in the risk of reoperation between weekday and weekend when comparing day of fracture or day of surgery.Interpretation - Patients who suffered a hip fracture during a weekend had slightly increased mortality in the first 2 months postoperatively. Whether the surgery was done on weekdays or at weekends did not affect mortality or the risk of reoperation.

Cognitive impairment influences the risk of reoperation after hip fracture surgery: results of 87,573 operations reported to the Norwegian Hip Fracture Register.

Background and purpose - About one-fourth of hip fracture patients have cognitive impairment. We investigated whether patients' cognitive function affects surgical treatment, risk of reoperation, and mortality after hip fracture, based on data in the Norwegian Hip Fracture Register (NHFR).Patients and methods - This prospective cohort study included 87,573 hip fractures reported to the NHFR in 2005-2017. Hazard rate ratios (HRRs) for risk of reoperation and mortality were calculated using Cox regression adjusted for sex, age, ASA class, fracture type, and surgical method.Results - Cognitive impairment was reported in 27% of patients. They were older (86 vs. 82 years) and had higher ASA class than non-impaired patients. There were no differences in fracture type or operation methods. Cognitively impaired patients had a lower overall reoperation rate (4.7% vs. 8.9%, HRR 0.71; 95% CI 0.66-0.76) and lower risk of reoperation after osteosynthesis (HRR 0.58; CI 0.53-0.63) than non-impaired patients. Cognitively impaired hip fracture patients had an increased reoperation risk after hemiarthroplasty (HRR 1.2; CI 1.1-1.4), mainly due to dislocations (1.5% vs. 1.0%, HRR 1.7; CI 1.3-2.1). Risk of dislocation was particularly high following the posterior approach (4.7% vs. 2.8%, HRR 1.8; CI 1.2-2.7). Further, they had a higher risk of reoperation due to periprosthetic fracture after uncemented hemiarthroplasty (HRR 1.6; CI 1.0-2.6). Cognitively impaired hip fracture patients had higher 1-year mortality than those without cognitive impairment (38% vs. 16%, HRR 2.1; CI 2.1-2.2).Interpretation - Our findings support giving cognitively impaired patients the same surgical treatment as non-impaired patients. But since the risk of hemiprosthesis dislocation and periprosthetic fracture was higher in cognitively impaired patients, they should probably not have posterior approach surgery or uncemented implants.

Validation of orthopaedic surgeons' assessment of cognitive function in patients with acute hip fracture.

BACKGROUND: About one fourth of patients with hip fracture have cognitive impairment. These patients are at higher risk of surgical and medical complications and are often excluded from participating in clinical research. The aim of the present study was to investigate orthopaedic surgeons' ability to determine the cognitive status of patients with acute hip fracture and to compare the treatment given to patients with and without cognitive impairment. METHODS: The cognitive function of 1474 hip fracture patients reported by the orthopaedic surgeons to the nationwide Norwegian Hip Fracture Register was compared with data registered in quality databases in two hospitals with orthogeriatric service on the same patients. Cognitive function registered in the quality databases was determined either by the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or by pre-fracture diagnosis of dementia. The information registered in the quality databases was defined as the reference standard. Cognitive function in the Norwegian Hip Fracture Register was reported as: Chronic cognitive impairment? "Yes", "Uncertain" or "No" by the orthopaedic surgeons. Sensitivity, specificity, negative and positive predictive values for chronic cognitive impairment reported to the Norwegian Hip Fracture Register by the orthopaedic surgeons was calculated. Baseline data and treatment of hip fractures in patients with and without cognitive impairment in the Norwegian Hip Fracture Register were compared. RESULTS: Orthopaedic surgeons reported chronic cognitive impairment in 31% of the patients. Using documented dementia or IQCODE > 4.0 as the reference, this assessment of cognitive impairment by the orthopaedic surgeons had a sensitivity of 69%, a specificity of 90%, a positive predictive value of 78%, and a negative predictive value of 84% compared to information registered in the two hospital quality databases. There were no differences in type of hip fracture or type of surgical treatment by cognitive function. CONCLUSION: The treatment of hip fractures was similar in patients with chronic cognitive impairment and cognitively well-functioning patients. The surgeons had an acceptable ability to identify and report chronic cognitive impairment in the peri-operative period, indicating that the Norwegian Hip Fracture Register is a valuable resource for future registry-based research also on hip fracture patients with chronic cognitive impairment.

A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994-2016.

BACKGROUND: The aim of this study was to present the long-term survivorship (20 years) of total elbow arthroplasty (TEA) for a relatively large population and to compare different prosthesis brands and patient subgroups. METHODS: Between 1994 and 2017, a total of 838 primary TEAs were reported to the Norwegian Arthroplasty Register. Implant survival was calculated using the Kaplan-Meier method. Risk differences were examined using Cox regression analyses and exact Cox regression for rare events. We compared the survivorship of the 8 most frequently used implant brands, the different diagnoses leading to TEA, and the influence of the fixation technique. RESULTS: The overall 5-, 10-, 15-, and 20-year survival rates for all elbow arthroplasties were 92%, 81%, 71%, and 61%, respectively. Risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. There were some differences between the implant brands. The Norway prostheses had higher survival compared with the Kudo after 15 years of follow-up (78% and 66%, respectively; P < .001). Among the implants with shorter follow-up, the IBP and NES had inferior survivorship compared with the Norway. The frequently used Discovery had promising survivorship up to 5 years. The most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, infection, and dislocation. The revision causes were to some degree implant specific. CONCLUSION: Fairly good results in terms of prosthesis survival were obtained with TEA, although results were poorer than for knee and hip arthroplasties.

Low-molecular-weight heparin for hip fracture patients treated with osteosynthesis: should thromboprophylaxis start before or after surgery? An observational study of 45,913 hip fractures reported to the Norwegian Hip Fracture Register.

Background and purpose - Controversies exist regarding thromboprophylaxis in orthopedic surgery. We studied whether the thromboprophylaxis in hip fracture patients treated with osteosynthesis should start preoperatively or postoperatively. Data were extracted from the nationwide Norwegian Hip Fracture Register (NHFR). The risks of postoperative deaths, reoperations, and intraoperative bleeding were studied within 6 months after surgery. Patients and methods - After each operation for hip fracture in Norway the surgeon reports information on the patient, the fracture, and the operation to the NHFR. Cox regression analyses were performed with adjustments for age group, ASA score, sex, duration of surgery, and year of surgery. During the period 2005-2016, 96,599 hip fractures were reported to the register. Only osteosyntheses where low-molecular-weight heparin (LMWH) were given and with known information on preoperative start of the prophylaxis were included in the analyses. Dalteparin and enoxaparin were used in 58% and 42% of the operations respectively (n = 45,913). Results - Mortality (RR =1.01, 95% CI 0.97-1.06) and risk of reoperation (RR =0.99, CI 0.90-1.08) were similar comparing preoperative and postoperative start of LMWH. Postoperative start reduced the risk of intraoperative bleeding complications compared with preoperative start (RR =0.67, CI 0.51-0.90). Interpretation - The initiation of LMWH did not influence the mortality or the risk of reoperation in hip fracture patients treated with osteosynthesis. Postoperative start of LMWH could possibly decrease the risk of intraoperative bleeding.

Similar Clinical Outcomes with Preoperative and Postoperative Start of Thromboprophylaxis in THA: A Register-based Study.

BACKGROUND: Elective THA is associated with a high risk of thromboembolic events. Although these events may be less common now than they were in the past, they can be serious, and most patients undergoing the procedure therefore still receive thromboprophylaxis. However, controversy remains regarding whether to begin thromboprophylaxis before THA or after to best balance the risks of clotting and bleeding. QUESTIONS/PURPOSES: We asked the following questions: (1) Is there a difference in bleeding events with pre- versus postoperative thromboprophylaxis? (2) Is there a difference in thromboembolic episodes after THA between the two regimens? (3) How do the two approaches of thromboprophylaxis influence mortality, readmissions, and other complications? METHODS: We used a population-based followup design with predefined data based on international health codification to assess clinical effects of LMWH prophylaxis initiated before or after THA. We took data limited to primary THAs done in Norway between January 1, 2008, and December 31, 2011, from the Norwegian Arthroplasty Register and the National Patient Register to have necessary data elements to complete the study. The two registers were merged after identifying patients with their 11-digit personal identification number (Social Security number). We obtained data regarding demographics, administrative and surgical details, and episode histories for prophylaxis-related events within 180 days of surgery. A total of 25,163 patients undergoing THA were included for analysis, and 9977(40%) versus 15,186 (60%) patients received pre- and postoperative LMWH, respectively. We performed statistical adjustment for differences in baseline characteristics using multivariate logistic regression. RESULTS: After adjustment for age, sex, operation time, year of surgery, and American Society of Anesthesiologists class, we could not show major differences in bleeding events; (odds ratio [OR], 1.04; 95% CI, 0.88-1.22; p = 0.660), thromboembolic episodes; (OR, 1.03; 95% CI, 0.84-1.27; p = 0.786), or other postoperative clinical complications; (OR, 0.86; 95% CI, 0.76-0.99; p = 0.034), with the two regimens. Six-month mortality was similar, (OR, 0.76; 95% CI, 0.56-1.05; p = 0.093), and the readmission rate was higher in the preoperative group; (OR, 0.92; 95% CI, 0.85-0.97; p = 0.016). CONCLUSIONS: The risk for postoperative complications seems to be comparable whether LMWH prophylaxis is initiated before or after THA. The postoperative approach reduces costs, decreases risks related to neuraxial anesthesia, and facilitates same-day admissions. Methods for individual risk assessment including laboratory tests would be feasible. LEVEL OF EVIDENCE: Level III, therapeutic study.

Postoperative start compared to preoperative start of low-molecular-weight heparin increases mortality in patients with femoral neck fractures.

Background and purpose - Controversies exist regarding thromboprophylaxis in orthopedic surgery. Using data in the nationwide Norwegian Hip Fracture Register (NHFR) with postoperative death and reoperation in the first 6 months after surgery as endpoints in the analyses, we determined whether the thromboprophylaxis in patients who undergo hemiarthroplasty for femoral neck fracture should start preoperatively or postoperatively. Patients and methods - After each operation for hip fracture in Norway, the surgeon reports information on the patient, the fracture, and the operation to the NHFR. Cox regression analyses were performed with adjustments for age, ASA score, gender, type of implant, length of surgery, and year of surgery. Results - During the period 2005-2014, 25,019 hemiarthroplasties as treatment for femoral neck fractures were reported to the registry. Antithrombotic medication was given to 99% of the patients. Low-molecular-weight heparin predominated with dalteparin in 57% of the operations and enoxaparin in 41%. Only operations with these 2 drugs and with known information on preoperative or postoperative start of the prophylaxis were included in the analyses (n = 20,241). Compared to preoperative start of thromboprophylaxis, postoperative start of thromboprophylaxis gave a higher risk of death (risk ratio (RR) = 1.13, 95% CI: 1.06-1.21; p < 0.001) and a higher risk of reoperation for any reason (RR =1.19, 95% CI: 1.01-1.40; p = 0.04), whereas we found no effect on reported intraoperative bleeding complication or on the risk of postoperative reoperation due to hematoma. The results did not depend on whether the initial dose of prophylaxis was the full dosage or half of the standard dosage. Interpretation - Postoperative start of thromboprophylaxis increased the mortality and risk of reoperation compared to preoperative start in femoral neck fracture patients operated with hemiprosthesis. The risks of bleeding and of reoperation due to hematoma were similar in patients who received low-molecular-weight heparin preoperatively and in those who received it postoperatively.

Improved outcome after hip fracture surgery in Norway.

Background and purpose - The operative treatment of hip fractures in Norway has changed considerably during the last decade. We used data in the Norwegian Hip Fracture Register to investigate possible effects of these changes on reoperations and 1-year mortality. Patients and methods - 72,741 femoral neck (FFN) fractures and trochanteric fractures in patients 60 years or older were analyzed. The fractures were divided into 5 time periods (2005-2006, 2007-2008, 2009-2010, 2011-2012, 2013-2014). Cox regression models were used to calculate unadjusted and adjusted (age group, sex, and ASA class) relative risks (RRs) of reoperation and of 1-year mortality in the different time periods. Results - For undisplaced FFNs treatment with hemiarthroplasty increased from 2.1% to 9.7% during the study period. For displaced FFNs treatment with arthroplasty increased from 56% to 93%. The use of intramedullary nails increased from 9.1% to 26% for stable 2-fragment (AO/OTA A1) trochanteric fractures, from 15% to 33% for multifragment (AO/OTA A2) trochanteric fractures, and from 27% to 61% for intertrochanteric fractures (AO/OTA A3)/subtrochanteric fractures. Compared with the first time period the adjusted 1-year RR for reoperation was 0.43 (95% CI: 0.37-0.49) for displaced FFNs in the last time period. The adjusted 1-year mortality in the last time period was lower for all fractures (RR: 0.87 (0.83-0.91)), displaced FFNs (RR: 0.86 (0.80-0.93)), AO/OTA A1 trochanteric fractures (RR: 0.79 (0.71-0.88)), and AO/OTA A2 trochanteric fractures (RR: 0.87 (0.77-0.98)) when compared with the first study period. Interpretation - Hip fracture treatment in Norway has improved: The risk of reoperation and the 1-year mortality after displaced femoral neck fractures have decreased over a 10-year period. National registration is useful to monitor trends in treatment and outcomes after hip fractures.

Pelvic irradiation does not increase the risk of hip replacement in patients with gynecological cancer. A cohort study based on 8,507 patients.

BACKGROUND AND PURPOSE: Long-term survivors of cancer can develop adverse effects of the treatment. 60% of cancer patients survive for at least 5 years after diagnosis. Pelvic irradiation can cause bone damage in these long-term survivors, with increased risk of fracture and degeneration of the hip. PATIENTS AND METHODS: Analyses were based on linkage between the Cancer Registry of Norway (CRN) and the Norwegian Arthroplasty Register (NAR). All women who had been exposed to radiation for curative radiotherapy of gynecological cancer (40-60 Gy for at least 28 days) were identified in the CRN. Radiotherapy had been given between 1998 and 2006 and only patients who were irradiated within 6 months of diagnosis were included. The control group contained women with breast cancer who had also undergone radiotherapy, but not to the pelvic area. Fine and Gray competing-risk analysis was used to calculate subhazard-rate ratios (subHRRs) and cumulative incidence functions (CIFs) for the risk of having a prosthesis accounting for differences in mortality. RESULTS: Of 962 eligible patients with gynecological cancer, 26 (3%) had received a total hip replacement. In the control group without exposure, 253 (3%) of 7,545 patients with breast cancer had undergone total hip replacement. The 8-year CIF for receiving a total hip replacement was 2.7% (95% CI: 2.6-2.8) for gynecological cancer patients and 3.0% (95% CI: 2.95-3.03) for breast cancer patients; subHRR was 0.80 (95% CI: 0.53-1.22; p=0.3). In both groups, the most common reason for hip replacement was idiopathic osteoarthritis. INTERPRETATION: We did not find any statistically significantly higher risk of undergoing total hip replacement in patients with gynecological cancer who had had pelvic radiotherapy than in women with breast cancer who had not had pelvic radiotherapy.

Patient-reported outcome measures in hip fracture patients.

Aims: The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods: Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results: The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion: Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients' health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment.

Five-Year Results of the Salto XT Revision Ankle Arthroplasty.

BACKGROUND: The treatment of failed ankle replacements is debated, and little is published about the medium- and long-term results of revision implants. We wanted to examine prosthesis survival and physical function at least 5 years after insertion of the Salto XT revision prosthesis. METHODS: All consecutive patients operated with a Salto XT revision prosthesis underwent clinical and radiologic examinations preoperatively and after 3, 12, 24, and 60 months. Complications and reoperations are described, and changes in patient-reported outcome measures and clinical scores are reported. RESULTS: Thirty patients were operated with a Salto XT revision prosthesis between March 2014 and March 2017. Three of these were revised (1 to a fusion and 2 to a new prosthesis), and 3 patients were reoperated with screw removal. A concurrent subtalar fusion was performed on 13 patients, and there was 1 case of likely nonunion after these procedures, but no reoperations. The mean AOFAS score increased from 39.2 (95% CI 30.8-47.5) preoperatively to 75.1 (95% CI 67.3-82.9) after 5 years, and the mean improvement was 34.2 points (95% CI 23.8-44.6). Mean EQ-5D increased from 0.36 (95% CI 0.30-0.42) preoperatively to 0.74 (95% CI 0.64-0.85) after 5 years, an improvement of 0.34 (95% CI 0.19-0.49). Radiolucent lines were present in all but 3 patients. Five-year prosthesis survival was 93% (83.6-100). CONCLUSION: This is the first study to present medium-term results of this implant. We found good improvement in outcome scores and good implant survival, but also a high prevalence of radiolucent lines.

Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020.

Aims: This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods: We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results: In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion: This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment.