Percutaneous intramedullary screw or rush pin fixation of unstable ankle fractures in patients with fragile soft tissue - retrospective study of 80 cases.

INTRODUCTION: The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin. MATERIALS AND METHODS: We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities. RESULTS: Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing. CONCLUSIONS: Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

Poor usability of computer-assisted navigation for hip fracture surgery.

INTRODUCTION: The STRYKER ADAPT computer-assisted navigation system provides intraoperative feedback to the surgeon regarding implant placement of the Gamma3 nail. The usability of the ADAPT system has not been evaluated. The aim of the study was to investigate the perceived usability of the ADAPT system. MATERIALS AND METHODS: This was a descriptive study with prospectively collected data. ADAPT was introduced at Aarhus University Hospital in February 2021. Prior to introduction, surgeons at the department attended a general introduction to the system. ADAPT was introduced to the surgical nurses and was on display at the surgical ward at more than one occasion, where personal introduction to the system was possible. After introduction, it was mandatory to use ADAPT when using the Gamma3 nail to treat intertrochanteric femur fractures. After each procedure, primary and an eventual supervisor answered a questionnaire, which encompassed the System Usability Scale (SUS) questionnaire. The SUS is a ten-item questionnaire regarding the perceived usability of a system. SUS scores were translated to adjectives, describing user experience on a 7-point adjective scale (worst imaginable, awful, poor, ok, good, excellent, best imaginable). User acceptability, defined as "not acceptable", "marginal" or "acceptable", was also used to interpret the SUS scores. RESULTS: ADAPT was used in 50 procedures by 29 different surgeons, with varying skill-level. Median SUS-score after first-time use of ADAPT for all 29 surgeons was 43 (range: 5-60), which translated to "poor" or "not acceptable". For surgeons who performed ≥ 3 ADAPT-assisted procedures, there were no statistically significant difference in their first to latest SUS-score (median difference: 4.3, p = 0.5). In free text comments ADAPT was positively described as helpful in placement of K-wire and providing educational opportunities for inexperienced surgeons and negatively as inconsistent, slow, time consuming, and causing excessive fluoroscopy. CONCLUSIONS: Usability and acceptability of ADAPT was rated as "poor" or "not acceptable" by the majority of operating surgeons. ADAPT has not been used at our institution based on these findings. The System Usability Scale may be used in further research exploring usability and acceptability of novel computer-assisted navigation systems for orthopaedic surgery.

Enhancing the data capture of periprosthetic joint infections in the Danish Knee Arthroplasty Registry: validity assessment and incidence estimation.

BACKGROUND AND PURPOSE: Revisions due to periprosthetic joint infection (PJI) are underestimated in national arthroplasty registries. Our primary objective was to assess the validity in the Danish Knee Arthroplasty Register (DKR) of revisions performed due to PJI against the Healthcare-Associated Infections Database (HAIBA). The secondary aim was to describe the cumulative incidences of revision due to PJI within 1 year of primary total knee arthroplasty (TKA) according to the DKR, HAIBA, and DKR/HAIBA combined. METHODS: This longitudinal observational cohort study included 56,305 primary TKAs (2010-2018), reported in both the DKR and HAIBA. In the DKR, revision performed due to PJI was based on pre- and intraoperative assessment disclosed by the surgeon immediately after surgery. In HAIBA, PJI was identified from knee-related revision procedures coinciding with 2 biopsies with identical microbiological pathogens. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of revision due to PJI in the DKR (vs. HAIBA, within 1 year of TKA) with 95% confidence intervals (CI). Cumulative incidences were calculated using the Kaplan-Meier method. RESULTS: The DKR's sensitivity for PJI revision was 58% (CI 53-62) and varied by TKA year (41%-68%) and prosthetic type (31% for monoblock; 63% for modular). The specificity was 99.8% (CI 99.7-99.8), PPV 64% (CI 62-72), and NPV 99.6% (CI 99.6-99.7). 80% of PJI cases not captured by the DKR were caused by non-reporting rather than misclassification. 33% of PJI cases in the DKR or HAIBA were culture-negative. Considering potential misclassifications, the best-case sensitivity was 64%. The cumulative incidences of PJI were 0.8% in the DKR, 0.9% in HAIBA, and 1.1% when combining data. CONCLUSION: The sensitivity of revision due to PJI in the DKR was 58%. The cumulative incidence of PJI within 1 year after TKA was highest (1.1%) when combining the DKR and HAIBA, showing that incorporating microbiology data into arthroplasty registries can enhance PJI validity.

Comparison of four patient reported outcome measures in patients with ankle fracture: A study on patient preferences and psychometric properties.

BACKGROUND: The aim was to assess psychometric properties of Manchester Oxford Foot Questionnaire (MOXFQ), the Self-reported Foot and Ankle Score (SEFAS), the Olerud Molander Ankle Score (OMAS), and the Forgotten Joint Score (FJS) in adults with ankle fractures. METHODS: Patients received all four questionnaires 6, 12, 14, 24, 52, and 104 weeks following an ankle fracture. According to COSMIN guidelines, statistical tests were performed to assess floor- and ceiling effects, structural validity, construct validity and reliability. Cognitive interview was performed with 9 patients. RESULTS: MOXFQ showed best model fit in Confirmatory Factor Analysis. When testing construct validity, all hypotheses were accepted except for OMAS and FJS. All questionnaires had an almost perfect test-retest reliability (Interclass Correlation Coefficient 0.81 to 0.91) and Cronbach's alpha ranged from 0.76 to 0.95. MOXFQ was the best rated questionnaire. CONCLUSION: All questionnaires performed well and we recommend MOXFQ for future use in ankle fracture studies. LEVEL OF EVIDENCE: Level IV.

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.

Temporal trends in revision rate due to knee periprosthetic joint infection: a study of 115,120 cases from the Danish Knee Arthroplasty Register.

BACKGROUND AND PURPOSE: We aimed to examine the temporal trends in periprosthetic joint infection (PJI) revision incidence after knee arthroplasty (KA) from 1997 through 2019. PATIENTS AND METHODS: 115,120 primary KA cases from the Danish Knee Arthroplasty Register were followed until the first PJI revision. We computed cumulative incidences and adjusted hazard ratios (aHRs) of PJI revision by calendar periods and several patient- and surgical-related risk factors. Results were analyzed from 0-3 months and from 3-12 months after KA. RESULTS: The overall 1-year PJI revision incidence was 0.7%, increasing from 0.5% to 0.7% (1997 through 2019). The incidence of PJI revision within 3 months increased from 0.1% to 0.5% (1997 through 2019). The adjusted hazard ratio (aHR) within 1 year of primary KA was 5.1 comparing 2017-2019 with 2001-2004. The PJI revision incidence from 3-12 months of KA decreased from 0.4% to 0.2%, with an aHR of 0.5 for 2017-2019 vs. 2001-2004. Male sex, age 75-84 (vs. 65-74), and extreme obesity (vs. normal weight) were positively associated with the risk of PJI revision within 3 months, whereas only male sex was associated from 3-12 months. Partial knee arthroplasty (PKA) vs. total KA was associated with a lower risk of PJI revision both within 3 months and 3-12 months of KA. CONCLUSION: We observed an increase in PJI revision within 3 months of KA, and a decrease in PJI revision incidence from 3-12 months from 1997 through 2019. The reasons for this observed time-trend are thought to be multifactorial. PKA was associated with a lower risk of PJI revision.

Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016.

BACKGROUND AND PURPOSE: The choice between invasive and non-invasive treatment of diaphyseal forearm fractures in children can be difficult. We investigated the trends in choice of treatment of pediatric diaphyseal forearm fractures over a 20-year period.  Patients and methods: This is a population-based register study with data from 1997 to 2016 retrieved from the Danish National Patient Registry. The primary outcome was choice of primary treatment within 1 week divided into non-invasive treatment (casting only or closed reduction including casting) and invasive (Kirshner wires, intramedullary nailing [IMN], and open reduction internal fixation [ORIF]). The secondary outcomes were further sub-analyses on invasive treatment and age groups. RESULTS: 36,244 diaphyseal forearm fractures were investigated, yielding a mean incidence of 172 per 105/year. The proportion of fractures treated invasively increased from 1997 to 2016, from 4% to 23%. The use of Kirschner wires increased from 1% to 9%, IMN increased from 1% to 14%, and ORIF decreased from 2% to 1%. The changes were evident in all age groups but smaller in the 0-3-year age group. CONCLUSION: We found an increase in invasive treatment of pediatric diaphyseal forearm fractures over the investigated period. A change in invasive methods was also found, as the rate of IMN increased over the investigated period and became the predominant surgical treatment choice.

Epidemiology and trends in management of acute proximal humeral fractures in adults: an observational study of 137,436 cases from the Danish National Patient Register, 1996-2018.

BACKGROUND AND PURPOSE: Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates have been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery. We describe the epidemiology and trends in management of acute PHF in Denmark with a focus on (i) changes in the incidence of PHF; (ii) changes in the proportion of surgical cases; and (iii) changes in preferred surgical techniques. PATIENTS AND METHODS: Data on diagnoses and interventions was retrieved from the Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as the diagnosis of PHF combined with a predefined surgical procedure code within 3 weeks of injury. Data on plate osteosynthesis, HA, RSA, and "other techniques" was retrieved. Non-surgical treatment was defined as no relevant surgical procedure code within 3 weeks. RESULTS: We identified 137,436 PHF (72% women) in the Danish National Patient Register. The overall mean incidence was 138/100,000/year (500 for women 60 years or above). Non-surgical treatment accounted for 119,966 (87%). The 17,470 surgical procedures included 42% locking plates, 34% arthroplasties, and 25% other techniques. The rate of surgery declined from 17% in 2013 to 11% in 2018. INTERPRETATION: The overall incidence of PHF remained stable between 1996 and 2018 but the absolute number increased. The approach to PHF remains predominantly non-surgical. The number of surgeries in Denmark have decreased since 2013, especially for locking plates and HA, while RSA is increasingly used.

Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate.

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.

A Single Positive Tissue Culture Increases the Risk of Rerevision of Clinically Aseptic THA: A National Register Study.

BACKGROUND: The diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear in diagnosing prosthetic joint infection (PJI) in THA revisions. QUESTIONS/PURPOSES: Therefore, we asked: (1) What is the clinical importance of bacterial growth in intraoperative tissue cultures taken during first-time revision of a clinically aseptic THA in terms of all-cause rerevision and rerevision for PJI specifically? (2) Is there a difference in outpatient antibiotic treatment patterns that is dependent on the number of positive intraoperative cultures? METHODS: This register-based study included all procedures reported to the Danish Hip Arthroplasty Register (DHR) as first-time aseptic loosening revisions performed during January 2010 to May 2016. DHR data were merged with that of the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Both registers have been validated and have a very high degree of completeness and very few patients are missing as a result of emigration. Revisions were grouped based on the number of unexpected positive cultures growing the same bacterial genus: zero, one, or two or more cultures. We defined a positive culture as "unexpected" if it was observed after a revision THA that had been reported to the DHR as aseptic. In Denmark, cultures are routinely obtained even in revisions coded as aseptic, and in this report, 91% (2090 of 2305) of the revision THAs coded as aseptic had cultures taken. The revisions were followed until rerevision, death, or end of the 1-year followup period. The relative risk for rerevision resulting from all causes and PJI was estimated. The Danish National Prescription Registry was reviewed for outpatient antibiotic prescription within 6 weeks of revision. We included 2305 first-time aseptic revisions. Unexpected growth was found in 282 THAs (12%), of which 170 (60%) had growth in only one culture or mixed microbial growth. Coagulase-negative Staphylococcus was the dominating bacteria in 121 revisions (71%). Rerevision was performed on 163 THAs (7%) with PJI being the indication for rerevision in 43 THAs (26%). RESULTS: The risk of all-cause rerevision was greater among first-time revisions with one positive culture (relative risk [RR], 1.73; 95% confidence interval [CI], 1.07-2.80; p = 0.020), but not in the two or more positive group (RR, 1.52; 95% CI, 0.82-2.80; p = 0.180) when compared with the culture-negative THAs. First-time revisions with one positive culture also had a higher risk of rerevision for PJI specifically (RR, 2.63; 95% CI, 1.16-5.96; p = 0.020), but this was not the case in the two or more positive group (RR, 2.28; 95% CI, 0.81-6.43; p = 0.120). Outpatient antibiotic prescription was more frequent after revisions with two or more positive cultures compared with culture-negative revision (50 of 112 [45%] versus 353 of 2023 [17%]; p < 0.001). This was not the case in revisions with one positive culture (36 of 170 [21%] versus 353 of 2023 [17%]; p = 0.220). CONCLUSIONS: First-time clinically aseptic THA revisions with unexpected growth in one biopsy culture had an increased risk for rerevision, both in terms of all-cause revision and revision for PJI. The predominant bacteria in revisions with later rerevision was coagulase-negative Staphylococcus. This emphasizes that unexpected bacterial growth with common bacteria may be clinically important, even if only one of five biopsy cultures is positive. LEVEL OF EVIDENCE: Level III, therapeutic study.

Prevalence and Impact of Diabetes Mellitus on the Frozen Shoulder.

OBJECTIVES: The objective of this study was to estimate the prevalence of undiagnosed diabetes mellitus in patients with newly diagnosed frozen shoulder (FS) and study whether diabetes mellitus increases the severity of FS disease. METHODS: Patients with newly diagnosed FS were consecutively included in this case-control study. Patients who were not already diagnosed as having diabetes mellitus were invited to be tested with the hemoglobin A1c blood sample test. The study population was compared with a control group, consisting of five individuals from the general population matched on age and sex. The passive range of motion, Oxford Shoulder Score, and visual analog scale (VAS) for average and maximum daily pain was recorded for all of the patients in the study group. RESULTS: A total of 235 patients were included, 34 (14%) of whom were diagnosed as having diabetes mellitus before the examination. Of the remaining 201 patients, 122 (61%) agreed to be tested for diabetes mellitus. None of the tested patients had undiagnosed diabetes mellitus. This was not significantly different from the prevalence in the matched control population (P = 0.09). There was no difference between patients with and without diabetes mellitus in average daily VAS (P = 0.46) nor maximum daily VAS (P = 0.44). The Oxford Shoulder Score was similar in the two groups (P = 0.23) as was the range of motion. CONCLUSIONS: The prevalence of undiagnosed diabetes mellitus is low in patients with FS and does not differ from the general population. Diabetes mellitus does not seem to affect patients' perceived severity of an FS.

Increased Mortality After Prosthetic Joint Infection in Primary THA.

BACKGROUND: Revision for prosthetic joint infection (PJI) has a major effect on patients' health but it remains unclear if early PJI after primary THA is associated with a high mortality. QUESTIONS/PURPOSES: (1) Do patients with a revision for PJI within 1 year of primary THA have increased mortality compared with patients who do not undergo revision for any reason within 1 year of primary THA? (2) Do patients who undergo a revision for PJI within 1 year of primary THA have an increased mortality risk compared with patients who undergo an aseptic revision? (3) Are there particular bacteria among patients with PJI that are associated with an increased risk of death? METHODS: This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the register is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report). The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of followup, or, in case of a revision, 1 year from the date of revision. RESULTS: Within 1 year of primary THA, 8% (95% CI, 6%-11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54-3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (95% CI, 1.11-3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66-5.81) higher mortality risk than patients infected with other bacteria (p < 0.001). CONCLUSIONS: Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. This study should incentivize further studies on prevention of PJI and on risk to patients with the perspective to reduce mortality in patients who have had THA in general and for patients with PJI specifically. LEVEL OF EVIDENCE: Level III, therapeutic study.

The "true" incidence of surgically treated deep prosthetic joint infection after 32,896 primary total hip arthroplasties: a prospective cohort study.

BACKGROUND AND PURPOSE: It has been suggested that the risk of prosthetic joint infection (PJI) in patients with total hip arthroplasty (THA) may be underestimated if based only on arthroplasty registry data. We therefore wanted to estimate the "true" incidence of PJI in THA using several data sources. PATIENTS AND METHODS: We searched the Danish Hip Arthroplasty Register (DHR) for primary THAs performed between 2005 and 2011. Using the DHR and the Danish National Register of Patients (NRP), we identified first revisions for any reason and those that were due to PJI. PJIs were also identified using an algorithm incorporating data from microbiological, prescription, and clinical biochemistry databases and clinical findings from the medical records. We calculated cumulative incidence with 95% confidence interval. RESULTS: 32,896 primary THAs were identified. Of these, 1,546 had first-time revisions reported to the DHR and/or the NRP. For the DHR only, the 1- and 5-year cumulative incidences of PJI were 0.51% (0.44-0.59) and 0.64% (0.51-0.79). For the NRP only, the 1- and 5-year cumulative incidences of PJI were 0.48% (0.41-0.56) and 0.57% (0.45-0.71). The corresponding 1- and 5-year cumulative incidences estimated with the algorithm were 0.86% (0.77-0.97) and 1.03% (0.87-1.22). The incidences of PJI based on the DHR and the NRP were consistently 40% lower than those estimated using the algorithm covering several data sources. INTERPRETATION: Using several available data sources, the "true" incidence of PJI following primary THA was estimated to be approximately 40% higher than previously reported by national registries alone.

Is casting of displaced paediatric distal forearm fractures non-inferior to reduction under general anaesthesia? Study protocol for a pragmatic, randomized, controlled non-inferiority multicentre trial (the casting trial).

BACKGROUND: Treatment of displaced distal forearm fractures in children has traditionally been closed reduction and pin fixation, although they might heal and remodel without surgery with no functional impairment. No randomized controlled trials have been published comparing the patient-reported functional outcome following non-surgical or surgical treatment of displaced paediatric distal forearm fractures. METHODS: A multicentre non-inferiority randomized controlled trial. Children aged 4-10 years with a displaced distal forearm fracture will be offered inclusion, if the on-duty orthopaedic surgeon finds indication for surgical intervention. They will be allocated equally to non-surgical treatment (intervention) or surgical treatment of surgeon's choice (comparator). Follow-up will be 4 weeks and 3, 6, and 12 months. The primary outcome is the between-group difference in 12 months QuickDASH score. We will need a sample of 40 patients to show a 15-point difference with 80% power. DISCUSSION: The results of this trial may change our understanding of the healing potential of paediatric distal forearm fractures. If non-inferiority of non-surgical treatment is shown, the results may contribute to a reduction in future surgeries on children, who in turn can be treated without the risks and psychological burdens associated with surgery. TRIAL REGISTRATION: www. CLINICALTRIALS: gov (ID: NCT05736068). Date of registry: 17 February 2023.

Feasibility of Blood Flow Restriction Exercise in Adults with a Non-surgically Treated Achilles Tendon Rupture; a Case Series.

Blood flow restriction exercise (BFRE) appears to provide a unique opportunity to preserve lower limb muscle and function in patients with an Achilles tendon rupture. The purpose of this study was to investigate the feasibility of BFRE in patients with an Achilles tendon rupture. Additionally, to evaluate muscle volume and patient-reported ankle function, symptoms, complications, and physical activity following 12 weeks of BFRE. Feasibility was measured by adherence to training sessions, drop-out rate, intervention acceptability, ankle pain exacerbation (NRS), and adverse events. At baseline and 12-weeks follow-up, patients completed the Achilles Tendon Total Rupture Score questionnaire and had their thigh and calf circumference measured. At follow-up, patients' ability to perform a single-leg heel rise was tested. Sixteen of 18 patients completed the intervention and for those, adherence to training sessions was 88% ±16%. The mean NRS following BFRE sessions was 1.1 (95%CI: 1; 1.2). Three adverse events occurred during the 12 weeks. Two re-ruptures after completion of the BFRE program and one deep venous thrombosis following cast removal. BFRE was found to be feasible in a subset of patients with an Achilles tendon rupture. However, with three adverse events in a population of 18 patients, the effectiveness and safety of BFRE warrants further investigation.

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.

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.

Mortality in patients with trochanteric hip fractures (AO/OTA 31-A) treated with sliding hip screw versus intramedullary nail: A retrospective national registry study of 9547 patients from the Danish Fracture Database.

BACKGROUND: Whether trochanteric hip fractures (AO/OTA 31-A) should be treated with an intramedullary nail (IMN) or sliding hip screw (SHS) is debated. Recent studies suggest an association between IMN and excess mortality rates compared to SHS, but higher quality studies fail to show this association. Furthermore, there is an increased usage of IMN with sparse evidence supporting this rise. Our aim was to compare mortality rates between IMN and SHS in patients with AO/OTA 31-A fractures. Secondarily, to investigate choice of implant in relation to fracture subtype. METHODS: This national registry study is based on data from the Danish Fracture Database (DFDB). Data were retrieved on patients aged ≥65 years treated for a non-pathological AO/OTA type 31-A fracture with IMN or SHS from January 1, 2012 to December 31, 2018. Data from DFDB were merged with data from the Danish Civil Registration System (CRS) for time of death. Mortality rates were recorded at 30 days, 90 days, and 1 year and presented as crude mortality and adjusted for age, gender, ASA-class, and AO/OTA-subtype. RESULTS: A total of 9,547 patients were included. The mean age was 83 years, 69% were female, and 55% were ASA-class 3-5. We found higher mortality rates for IMN-patients at 30 days, 90 days, and 1 year. The crude relative mortality risk for IMN was also significantly higher at both 30 days (1.20) and 90 days (1.11). Adjusted relative mortality risk for IMN was 1.12 [0.96; 1.31] at 30-days, 1.03 [0.91; 1.17] at 90-days, and 1.01 [0.92; 1.11] at 1 year. Most patients suffered a 31-A2 fracture (56%) and, overall, 74% of patients were treated with IMN. CONCLUSION: We found significantly increased crude relative mortality risk at 30 days and 90 days in patients treated with IMN. However, when adjusting for confounders the two groups had similar mortality risks. In total, 74% of all patients in this cohort were treated with IMN. LEVEL OF EVIDENCE: This study has level of evidence: III.

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.