Predictive value of sarcopenia components for all-cause mortality: findings from population-based cohorts.

BACKGROUND: Low grip strength and gait speed are associated with mortality. However, investigation of the additional mortality risk explained by these measures, over and above other factors, is limited. AIM: We examined whether grip strength and gait speed improve discriminative capacity for mortality over and above more readily obtainable clinical risk factors. METHODS: Participants from the Health, Aging and Body Composition Study, Osteoporotic Fractures in Men Study, and the Hertfordshire Cohort Study were analysed. Appendicular lean mass (ALM) was ascertained using DXA; muscle strength by grip dynamometry; and usual gait speed over 2.4-6 m. Verified deaths were recorded. Associations between sarcopenia components and mortality were examined using Cox regression with cohort as a random effect; discriminative capacity was assessed using Harrell's Concordance Index (C-index). RESULTS: Mean (SD) age of participants (n = 8362) was 73.8(5.1) years; 5231(62.6%) died during a median follow-up time of 13.3 years. Grip strength (hazard ratio (95% CI) per SD decrease: 1.14 (1.10,1.19)) and gait speed (1.21 (1.17,1.26)), but not ALM index (1.01 (0.95,1.06)), were associated with mortality in mutually-adjusted models after accounting for age, sex, BMI, smoking status, alcohol consumption, physical activity, ethnicity, education, history of fractures and falls, femoral neck bone mineral density (BMD), self-rated health, cognitive function and number of comorbidities. However, a model containing only age and sex as exposures gave a C-index (95% CI) of 0.65(0.64,0.66), which only increased to 0.67(0.67,0.68) after inclusion of grip strength and gait speed. CONCLUSIONS: Grip strength and gait speed may generate only modest adjunctive risk information for mortality compared with other more readily obtainable risk factors.

Recovery pattern after decompression of central lumbar spinal stenosis: a prospective observational cohort study.

BACKGROUND: Detailed preoperative information is associated with superior outcomes. We aimed to describe the recovery pattern after decompression of central lumbar spinal stenosis (CLSS). METHODS: 50 patients aged 51-85 years who underwent decompression without fusion due to CLSS were followed from before to after surgery (post-op day 1, 7, and 14). Back and leg pain were evaluated using the Numeric Rating Scale (NRS; 0 = no pain 0, 10 = worst pain) and quality of life using the EuroQol-5D index (0 = death, 1 = best), and EQ-5D-visual analogue scale (VAS; 0 = worst, 100 = best). RESULTS: NRS leg pain was reduced from preoperative to first postoperative day by 5.2 (6.1, 4.3) (mean (95%CI)], and NRS back pain from postoperative day 1-7 by 0.6 (1.2, 0.03) and from day 7 to 14 by 0.7 (1.3, 0.2)]. In contrast, EQ-5D index increased from preoperative to first postoperative day by 0.09 (0.06, 0.13) and from day 1 to 7 by 0.05 (0.02,0.08), and EQ-5D VAS from preoperative to first postoperative day by 13.7 (9.1, 18.3) and from day 1 to 7 by 6.0 (2.0, 10.0). After two weeks, 51% of the patients had improved above the minimal clinically important difference (MCID) in back pain and 71% in leg pain. CONCLUSIONS: Patients scheduled for decompression due to CLSS should be informed that improvement in leg pain and quality of life in general can be expected within one day of surgery, that quality of life improves a little further in the first postoperative week, and that back pain improves in the first 2 postoperative weeks. In most patients, decompression without fusion due to CLSS seems to achieve clinically relevant improvement within 2 weeks.

Prevalence and morbidity of neck pain: a cross-sectional study of 3000 elderly men.

BACKGROUND: The purpose of this study is to determine the prevalence and morbidity of neck pain with or without cervical rhizopathy, upper extremity motor deficit and/or thoracolumbar pain in elderly men. METHODS: We conducted a cross-sectional questionnaire study of 3,000 community-dwelling older men with a mean age of 75.4 ± 3.2 years (range 69-81) to determine if they had experienced neck pain with or without cervical rhizopathy/upper extremity motor deficit/thoracolumbar pain (yes/no) during the preceding 12 months, and if so, morbidity with the condition (no/minor/moderate/severe). RESULTS: Among the participants, 865 (29%) reported they had experienced neck and 1,619 (54%) thoracolumbar pain. Among the men with neck pain, 59% had experienced only neck pain, 17% neck pain and cervical rhizopathy and 24% neck pain, rhizopathy and motor deficit. For men with only neck pain, the morbidity was severe in 13%, for men with neck pain and rhizopathy it was 24%, and for men with pain, rhizopathy and motor deficit it was 46% (p < 0.001). Among the men with neck pain, 23% had experienced only neck pain and no thoracolumbar pain; the remaining 77% had both neck and thoracolumbar pain. The morbidity was severe in 10% of the men with neck pain but no thoracolumbar pain and 30% in men with neck and thoracolumbar pain (p < 0.001). CONCLUSION: Neck pain in elderly men is common but symptoms and morbidity vary. For men who only have neck pain, 1/8 rated their morbidity as severe, while almost half who also had cervical rhizopathy and motor deficit and almost 1/3 of those who also had thoracolumbar pain reported severe morbidity.

Recent sarcopenia definitions-prevalence, agreement and mortality associations among men: Findings from population-based cohorts.

BACKGROUND: The 2019 European Working Group on Sarcopenia in Older People (EWGSOP2) and the Sarcopenia Definitions and Outcomes Consortium (SDOC) have recently proposed sarcopenia definitions. However, comparisons of the performance of these approaches in terms of thresholds employed, concordance in individuals and prediction of important health-related outcomes such as death are limited. We addressed this in a large multinational assembly of cohort studies that included information on lean mass, muscle strength, physical performance and health outcomes. METHODS: White men from the Health Aging and Body Composition (Health ABC) Study, Osteoporotic Fractures in Men (MrOS) Study cohorts (Sweden, USA), the Hertfordshire Cohort Study (HCS) and the Sarcopenia and Physical impairment with advancing Age (SarcoPhAge) Study were analysed. Appendicular lean mass (ALM) was ascertained using DXA; muscle strength by grip dynamometry; and usual gait speed over courses of 2.4-6 m. Deaths were recorded and verified. Definitions of sarcopenia were as follows: EWGSOP2 (grip strength <27 kg and ALM index <7.0 kg/m2 ), SDOC (grip strength <35.5 kg and gait speed <0.8 m/s) and Modified SDOC (grip strength <35.5 kg and gait speed <1.0 m/s). Cohen's kappa statistic was used to assess agreement between original definitions (EWGSOP2 and SDOC). Presence versus absence of sarcopenia according to each definition in relation to mortality risk was examined using Cox regression with adjustment for age and weight; estimates were combined across cohorts using random-effects meta-analysis. RESULTS: Mean (SD) age of participants (n = 9170) was 74.3 (4.9) years; 5929 participants died during a mean (SD) follow-up of 12.1 (5.5) years. The proportion with sarcopenia according to each definition was EWGSOP2 (1.1%), SDOC (1.7%) and Modified SDOC (5.3%). Agreement was weak between EWGSOP2 and SDOC (κ = 0.17). Pooled hazard ratios (95% CI) for mortality for presence versus absence of each definition were EWGSOP2 [1.76 (1.42, 2.18), I2 : 0.0%]; SDOC [2.75 (2.28, 3.31), I2 : 0.0%]; and Modified SDOC [1.93 (1.54, 2.41), I2 : 58.3%]. CONCLUSIONS: There was low prevalence and poor agreement among recent sarcopenia definitions in community-dwelling cohorts of older white men. All indices of sarcopenia were associated with mortality. The strong relationship between sarcopenia and mortality, regardless of the definition, illustrates that identification of appropriate management and lifecourse intervention strategies for this condition is of paramount importance.

A comparison study on patient-reported outcome between obese and non-obese patients with central lumbar spinal stenosis undergoing surgical decompression: 14,984 patients in the National Swedish Quality Registry for Spine Surgery.

BACKGROUND AND PURPOSE: Obesity has been associated with inferior outcomes after laminectomy due to central lumbar spinal stenosis (CLSS); we evaluated whether this occurs in surgery on national bases. PATIENTS AND METHODS: We retrieved pre- and 1-year postoperative data from the National Swedish Quality Registry for Spine Surgery regarding patients aged ≥ 50 with laminectomy due to CLSS in 2005-2018. 4,069 patients had normal weight, 7,044 were overweight, 3,377 had class I obesity, 577 class II obesity, and 94 class III obesity ("morbid obesity"). Patient-reported outcome included satisfaction after 1 year, leg pain (Numerical Rating Scale [NRS], rating 0-10), disability (Oswestry Disability Index [ODI], rating 0-100). Complications were also retrieved. RESULTS: 1-year postoperatively, 69% of patient of normal weight, 67% who were overweight, and 62% with obesity (classes I-III aggregated) were satisfied (p < 0.001) and 62%, 60%, and 57% in obese groups I-III, respectively (p = 0.7). NRS leg pain improved in normal-weight patients by 3.5 (95% CI 3.4-3.6), overweight by 3.2 (CI 3.1-3.2), and obese by 2.6 (CI 2.5-2.7), and 2.8 (CI 2.7-2.9), 2.5 (CI 2.2-2.7), and 2.6 (CI 2.0-3.2) in obese classes I-III, respectively. ODI improved in normal weight by 19 (CI 19-20), overweight by 17 (CI 17-18), and obese by 14 (CI 13-15), and 16 (CI 15-17), 14 (CI 13-16), 14 (CI 11-18) in obese classes I-III, respectively. 8.1% of normal weight, 7.0% of overweight, and 8.1% of obese patients suffered complications (p = 0.04) and 8.1%, 7.0%, and 17% among obese classes I-III, respectively (p < 0.01). CONCLUSION: Most obese patients are satisfied after laminectomy due to CLSS, even if satisfaction rate is inferior compared with normal-weight patients. The morbidly obese have more complications than patients with lower BMI.

A study comparing outcomes between obese and nonobese patients with lumbar disc herniation undergoing surgery: a study of the Swedish National Quality Registry of 9979 patients.

BACKGROUND: This study aimed to evaluate whether an increasing grade of obesity is associated with inferior outcomes after lumbar disc herniation (LDH) surgery. METHODS: We retrieved data from the Swedish register for spine surgery regarding patients aged 20-64 who underwent LDH surgery from 2006-2016 and had preoperative and one-year postoperative data. A total of 4156 patients were normal weight, 4063 were overweight, 1384 had class I obesity, 317 had class II obesity and 59 had class III obesity ("morbid obesity"). Data included patient satisfaction, improvement in leg pain (assessed using the National Rating Scale; NRS; rating 0-10), disability (assessed using the Oswestry Disability Index; ODI; rating 0-100) and complications. RESULTS: At one year postsurgery, 80% of normal-weight patients, 77% of overweight patients and 74% of obese patients (class I-III evaluated together) were satisfied (p < 0.001) [75%, 71%, 75% in obesity classes I, II, and III, respectively (p = 0.43)]. On average, all groups improved by more than the minimal clinically important difference (MCID) in both NRS leg pain (> 3.5) and ODI (> 20). NRS leg pain improved by 4.8 in normal weight patients (95% CI 4.7-4.9), by 4.5 in overweight patients (4.5-4.6) and by 4.3 in obese patients (4.2-4.4) (p < 0.001) [4.4 (4.3-4.6), 3.8 (3.5-4.1) and 4.6 (3.9-5.3) in obesity classes I, II, and III, respectively (p < 0.001)]. The ODI improved by 30 in normal weight patients (30-31), by 29 in overweight patients (28-29) and by 26 in obese patients (25-27) (p < 0.001) [29 (28-29), 25 (22-27) and 27 (22-32) in obesity classes I, II, and III, respectively (p < 0.01)]. A total of 3.0% of normal-weight patients, 3.9% of overweight patients and 3.9% of obese patients suffered complications (p = 0.047) [3.8%, 4.4%, 3.5% in obesity classes I, II, and III, respectively (p = 0.90)]. CONCLUSIONS: LDH surgery is also generally associated with favourable outcomes and few complications in patients with morbid obesity.

Outcomes of trabecular metal total ankle replacement: a longitudinal observational cohort study of 239 consecutive cases from the Swedish Ankle Registry.

BACKGROUND AND PURPOSE: Information on outcomes after some modern total ankle replacement (TAR) designs is scarce. We therefore examined outcomes after trabecular metal (TM) TAR in Sweden by use of data from the national registry. PATIENTS AND METHODS: On December 31, 2020, 239 primary TM TARs had been reported to the Swedish Ankle Registry. We analyzed prosthesis survival probability, using exchange or permanent extraction of components as endpoint for 239 protheses with mean follow-up of 2.2 years (0.1-6.6), risk of revision, as well as patient-reported outcome measures (SEFAS/EQ-5D/EQ-VAS) and satisfaction with surgery. RESULTS: 7/239 prostheses (3%) had been revised by December 31, 2020. We found an overall prosthesis survival probability of 95% (95% CI 89-98) after 3 years. 2 years after surgery 81% of the answering patients were satisfied or very satisfied with surgery and patients reported median SEFAS 36 (max 48), EQ-5D 0.90 (max 1), and EQ-VAS 80 (max 100). INTERPRETATION: We found short- to mid-term outcomes after TM TAR to be at least as good as after other TAR designs regarding prosthesis survival and patient-reported satisfaction.

Childhood Distal Forearm Fracture Incidence in Malmö, Sweden 1950 to 2016.

Background Distal forearm fracture is the most common pediatric fracture. As studies have indicated time trends in fracture incidence, we wanted to update the epidemiology and estimate time trends between 1950 and 2016 in Malmö, Sweden. Methods The city of Malmö, Sweden, had 318,107 inhabitants (58,585 of the population was aged <16 years) in 2014 and one hospital. We, therefore, used the hospital diagnosis registry and hospital medical records to identify and classify distal forearm fractures 2014 to 2016 in children aged 0 to 15 years. For long-term trend calculations, we also included published data from 1950 to 2006 (resulting in 17 evaluated years) and used joinpoint regression to estimate annual percent changes (APC). To describe differences in incidence between two periods, we calculated incident rate ratios (IRR) with 95% confidence intervals (95% CI) to describe uncertainty. Results Childhood distal forearm fracture incidence in 2014 to 2016 was 546/100,000 person-years (660 in boys and 427 in girls). The age-adjusted incidence in 2014 to 2016 and in 2005 to 2006 was similar (boys IRR 1.0, 95% CI: 0.9-1.2 and girls IRR 1.1, 95% CI: 0.9-1.3). Time-trend analyses from 1950 to 2016 revealed increasing age-adjusted incidence in both boys (APC +0.9%, 95% CI: 0.7-1.2) and girls (APC +0.6%, 95% CI: 0.3-0.9). Conclusion Distal forearm fracture incidence was similar in 2014 to 2016 and in 2005 to 2006. Age-adjusted incidence had increased in both sexes from 1950 to 2016. Level of Evidence This is a Level III b study.

Time trends in pediatric hand fracture incidence in Malmö, Sweden, 1950-2016.

BACKGROUND: The hand is the second most fractured region in children. It is therefore important to update fracture epidemiology to be able to identify time trends for adequate health care planning. This study reports pediatric hand fracture incidence 2014-2016 and, using published data, also long-term time trends in 1950-2016. PATIENTS AND METHODS: The Swedish city of Malmö, with 328,494 inhabitants in 2016, has only one hospital. We used the hospital radiological archive, medical charts, and diagnosis registry to identify hand fractures in city residents < 16 years in 2014-2016. These data were compared to those from three published studies that evaluated periods in 1950-2006. Differences between two periods were calculated as both unadjusted and age- and sex-adjusted incident rate ratios (IRR) with 95% confidence intervals (95% CI). We used joinpoint regression to estimate time trends during the entire period and present annual percent changes (APC) with 95% CI. RESULTS: In 2014-2016 phalangeal fractures accounted for 71% of all hand fractures, metacarpal fractures for 24%, and carpal fractures for 5%. We identified 615 hand fractures (419 in boys and 196 in girls) during 181,617 person-years in 2014-2016, resulting in an unadjusted pediatric hand fracture incidence of 339/100,000 person-years (boys 452/100,000 person-years and girls 220/100,000 person-years). The age-adjusted incidence 2014-2016 was similar to 2005-2006, the most recently evaluated period (IRR in boys 0.9; 95% CI 0.8 to 1.01, and in girls 1.0; 95% CI 0.8 to 1.2). Looking at the entire period 1950-2016, we found that age-adjusted incidence increased in 1950-1979, in boys by APC + 3.8%; 95% CI 3.0 to 4.5 and in girls by + 3.9%; 95% CI 2.8 to 5.0, but decreased in 1979-2016, in boys by - 0.7%; 95% CI - 1.4 to - 0.003, and girls by - 1.3%; 95% CI - 2.4 to - 0.1. CONCLUSIONS: Phalangeal fractures accounted for about three quarters of all hand fractures. The age-adjusted hand fracture incidence increased in both sexes in 1950-1979 and decreased in 1979-2016. LEVEL OF EVIDENCE: III.

Back pain is also improved by lumbar disc herniation surgery.

Background and purpose - Indication for lumbar disc herniation (LDH) surgery is usually to relieve sciatica. We evaluated whether back pain also decreases after LDH surgery.Patients and methods - In the Swedish register for spinal surgery (SweSpine) we identified 14,097 patients aged 20-64 years, with pre- and postoperative data, who in 2000-2016 had LDH surgery. We calculated 1-year improvement on numeric rating scale (rating 0-10) in back pain (Nback) and leg pain (Nleg) and by negative binomial regression relative risk (RR) for gaining improvement exceeding minimum clinically important difference (MCID).Results - Nleg was preoperatively (mean [SD]) 6.7 (2.5) and Nback was 4.7 (2.9) (p < 0.001). Surgery reduced Nleg by mean 4.5 (95% CI 4.5-4.6) and Nback by 2.2 (CI 2.1-2.2). Mean reduction in Nleg) was 67% and in Nback 47% (p < 0.001). Among patients with preoperative pain ≥ MCID (that is, patients with significant baseline pain and with a theoretical possibility to improve above MCID), the proportion who reached improvement ≥ MCID was 79% in Nleg and 60% in Nback. RR for gaining improvement ≥ MCID in smokers compared with non-smokers was for Nleg 0.9 (CI 0.8-0.9) and -Nback 0.9 (CI 0.8-0.9), and in patients with preoperative duration of back pain 0-3 months compared with > 24 months for Nleg 1.3 (CI 1.2-1.5) and for Nback 1.4 (CI 1.2-1.5).Interpretation - LDH surgery improves leg pain more than back pain; nevertheless, 60% of the patients with significant back pain improved ≥ MCID. Smoking and long duration of pain is associated with inferior recovery in both Nleg and Nback.

Better implant survival with modern ankle prosthetic designs: 1,226 total ankle prostheses followed for up to 20 years in the Swedish Ankle Registry.

Background and purpose - We have previously reported on the prosthetic survival of total ankle replacements (TAR) in Sweden performed between 1993 and 2010. Few other reports have been published on 5- and 10-year survival rates. Furthermore, there is a lack of long-term outcome data on modern prosthetic designs. Therefore, we compared early and current prosthetic designs after a mean 7-year follow-up.Patients and methods - On December 31, 2016, 1,230 primary TARs had been reported to the Swedish Ankle Registry. We analyzed prosthetic survival, using exchange or permanent extraction of components as endpoint for 1,226 protheses with mean follow-up of 7 years (0-24). Differences between current (Hintegra, Mobility, CCI, Rebalance, and TM Ankle) and early prosthetic designs (STAR, BP, and AES) were examined by log rank test.Results - 267/1,226 prostheses (22%) had been revised by December 31, 2016. We found an overall prosthetic survival rate at 5 years of 0.85 (95% CI 0.83-0.87), at 10 years 0.74 (CI 0.70-0.77), at 15 years 0.63 (CI 0.58-0.67), and at 20 years 0.58 (CI 0.52-0.65). For early prosthetic designs the 5- and 10-year survival rates were 0.81 (CI 0.78-0.84) and 0.69 (CI 0.64-0.73) respectively, while the corresponding rates for current designs were 0.88 (CI 0.85-0.91) and 0.84 (CI 0.79-0.88). Current prosthetic designs had better survival (log rank test p < 0.001).Interpretation - Our results point to a positive time trend of prosthetic survival in Sweden; use of current prosthetic designs was associated with better prosthetic survival. Improved designs and instrumentation, more experienced surgeons, and improved patient selection may all have contributed to the better outcome.

Smoking and Alcohol Intake but Not Muscle Strength in Young Men Increase Fracture Risk at Middle Age: A Cohort Study Linked to the Swedish National Patient Registry.

We aimed to determine the relationship between handgrip strength, smoking, and alcohol consumption in young men and fracture risk at middle age. Thus, we carried out a cohort study including young men undergoing conscription examination in Sweden from September 1969 to May 1970 at a typical age of 18 years. Data on muscle strength, height, weight, and lifestyle factors were linked to the National Patient Register 1987-2010. Handgrip strength was considered the main exposure and smoking and alcohol consumption as secondary exposures. Outcomes were all fractures (except face, skull, digits), major osteoporotic fractures (thoracic/lumbar spine, proximal humerus, distal forearm or hip), and major traumatic fractures (shaft of humerus, forearm, femur, or lower leg) based on ICD-9 and -10 codes. We used Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) according to handgrip strength as a continuous variable (per 1 SD), after adjustment for weight, height, parental education, smoking, and alcohol consumption. A total of 40,112 men were included, contributing 892,572 person-years. Overall, 3974 men fractured in middle age with the incidence rate (95% CI) of 44.5 (43.2-45.9) per 1000 person-years. The corresponding rates were12.2 and 5.6 per 1000 person-years for major osteoporotic and traumatic fractures, respectively. Handgrip strength-adjusted HR (95% CI) was 1.01 (0.98-1.05), 0.94 (0.88-1.00), and 0.98 (0.88-1.08) per SD for all, major osteoporotic, and major traumatic fractures, respectively. Adjusted HR (95% CI) for smokers (>21 cigarettes/d) was 1.44 (1.21, 1.71) for all fractures, while the association between alcohol consumption and hazards of fracture was J-shaped. Therefore, young adult handgrip strength was not associated with fracture risk in middle-age men, although smoking and high alcohol consumption did confer an increased risk. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

Pediatric Distal Forearm Fracture Epidemiology in Malmö, Sweden-Time Trends During Six Decades.

Background The distal forearm fracture is the most common fracture in children. To allocate health care resources and evaluate if prevention strategies have been successful, it is essential to monitor changes in the epidemiology of common fractures. Methods Our hospital serves a city in which year 2006 included 276,244 inhabitants (49,664 <17 years of age). Through the hospital archives, we identified fractures sustained by individuals younger than 16 years during 2005 and 2006 and compared these with previous collected and published data from the same area and hospital for the period 1950 to 1994. We used official population data to estimate period-specific fracture rates and age and gender standardized time trends. We report rates as number of fractures per 100,000 person-years and changes between periods as rate ratios (RR) with 95% confidence intervals (CIs). Results We identified 521 distal forearm fractures, corresponding to a crude fracture incidence of 564/100,000 person-years (boys 719; girls 401). Age-adjusted fracture incidence was 70% higher in boys than in girls (RR 1.7; 95% CI 1.3-2.3). The age- and gender-adjusted hand fracture incidence was 40% higher in 2005-2006 than in 1950/1955 (RR 1.4; 95% CI 1.2 to 1.8) but no higher than 1993-1994 (RR 1.1; 95% CI 0.9-1.3). Fracture etiology of 2005 to 2006 included sports injuries in 41% and traffic accidents in 11% of the cases, while sports injuries explained 37% and traffic accidents 18% in 1950 to 1955. Conclusion In 2005 to 2006, we found higher rates in boys and higher overall rates compared with the 1950s but no significant differences compared with the rates in 1993 to 1994. Future studies should include patient-specific data to unravel causal factors. Level of evidence This is a Level III b study.

Predictors of satisfaction after lumbar disc herniation surgery in elderly.

BACKGROUND: The aim of this study was to evaluate satisfaction and factors associated with satisfaction in elderly undergoing lumbar disc herniation surgery. METHODS: In the national Swedish register for spinal surgery (SweSpine) we identified 2095 patients aged > 65 years (WHO definition of elderly) whom during 2000-2016 had undergone LDH surgery and had pre- and one-year postoperative data (age, gender, preoperative duration and degree of back- and leg pain, quality of life (SF-36) and one-year satisfaction (dissatisfied, uncertain, satisfied). We utilized a logistic regression model to examine preoperative factors that were independently associated with low and high satisfaction and after LDH surgery. RESULTS: One year after surgery, 71% of the patients were satisfied, 18% uncertain and 11% dissatisfied. Patients who were satisfied were in comparison to others, younger, had shorter preoperative duration of leg pain, higher SF-36 mental component summary and more leg than back pain (all p < 0.01). Patients who were dissatisfied were compared to others older, had longer preoperative duration of leg pain and lower SF-36 scores (all p < 0.01). 81% of patients with leg pain up to 3 months were satisfied in comparison with 57% of patients with leg pain > 2 years (p < 0.001). CONCLUSION: Only one out of ten elderly, is dissatisfied with the outcome of LDH surgery. Age, preoperative duration of leg pain, preoperative SF 36 score, and for satisfaction also dominance of back over leg pain, are in elderly factors associated to good and poor subjective outcome after LDH surgery.

Hand fracture epidemiology and etiology in children-time trends in Malmö, Sweden, during six decades.

BACKGROUND: The aim of this study was to describe hand fracture epidemiology/etiology in city children and describe time trend during six decades. PATIENTS AND METHODS: A single hospital serves the entire city population of 271,271 (year 2005). Through the hospital medical and radiological archives, we collected epidemiology and etiology data concerning pediatric (age < 16 years) hand fractures in city residents, treated during 2005-2006. We compared these data to previously collected data in in the same city during 12 evaluated periods from 1950/1955 to 1993-1994. We present period-specific crude and age- and gender-adjusted fracture incidence rates and group differences as incidence rate ratios (RR) with 95% confidence intervals (95% CI). RESULTS: In 2005-2006, we identified 414 hand fractures (303 in boys and 111 in girls), 247 phalangeal fractures (60% of all hand fractures), 140 metacarpal/carpal fractures (except the scaphoid bone) (34%), and 27 scaphoid fractures (6%). The crude hand fracture rate in children was 448/100,000 person years (639/100,000 in boys and 247/100,000 in girls), with a 2.5 times higher age-adjusted incidence in boys than in girls. Compared to 1950/1955, the age and gender-adjusted hand fracture incidence was twice as high in 2005-2006 and more than twice as high in 1976-1979. Compared to 1976-1979, we found no significant difference in the age and gender-adjusted hand fracture incidence in 2005-2006. In 2005-2006, sports injuries explained 42%, fights 20%, and traffic accidents 13% of the hand fractures. In 1950/1955, sports injuries explained 27% of fractures, fights 10%, and traffic accidents 21%. CONCLUSIONS: The incidence of hand fractures in children was more than twice as high in the end of the 1970s compared to the 1950s, where after no significant change could be found. Also, fracture etiology has changed. New studies are needed, to adequately allocate health care resources and identify new fracture prone activities suitable for preventive measures. LEVEL OF EVIDENCE: III.

Age- and Gender-Specific Normative Values for the Self-Reported Foot and Ankle Score (SEFAS).

BACKGROUND: The Self-Reported Foot and Ankle Score (SEFAS) is a foot- and ankle-specific patient-reported outcome measurement (PROM) score that has been validated with good results for a variety of foot and ankle disorders. SEFAS is sensitive detecting improvement or deterioration after surgery. However, normative values, required to put a specific patient's summary score into perspective, are lacking. METHODS: In this report, we included 396 population-based men and 383 women (43% of the invited individuals), age 20-89 years, who had completed the SEFAS questionnaire and questions regarding anthropometrics and health. We used Mann-Whitney U test to test gender differences and Spearman correlation coefficients to determine any association between SEFAS score and age. We present gender-specific median SEFAS scores with range and 5th to 95th percentiles and mean with standard deviation. RESULTS: The SEFAS normative values were median 48 in men (range 11-48), 5th to 95th percentiles 31 to 48 and mean 45 ± 6, and in women, median 47 (range 6-48), 5th to 95th percentiles 23 to 48 and mean 43 ± 8 (gender comparison P < .001). SEFAS normative values correlated inversely with age (r = -0.12, P < .001). CONCLUSION: In the general population, older age was associated with lower SEFAS value, and men had higher values than women. The population-based normative SEFAS values provided in this study can facilitate quantification of disability related to foot and ankle with and without surgery in the foot and ankle. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Re-arthrodesis after primary ankle fusion: 134/1,716 cases from the Swedish Ankle Registry.

Background and purpose - Arthrodesis is the most common treatment of severe ankle arthritis. Large studies on the occurrence of re-arthrodesis are few, especially with information in terms of risk. We used the National Swedish Ankle Registry to assess incidence and risk factors for re-arthrodesis. Patients and methods - In the Registry, we examined the occurrence of re-arthrodesis in 1,716 patients with a primary ankle arthrodesis. We also analyzed associations between the re-arthrodesis risk and sex, diagnosis, and surgical method. Results - The risk of first re-arthrodesis at 2.5 years was 7.4% and the rate at 9 years 7.8%. The risk following arthroscopic surgery with fixation by screws was 15%, which is statistically significantly higher than the 8% following the gold standard technique with open screw fixation, the 5% following fixation by intramedullary nailing, and the 3% following fixation by plate and screws. Patients with either idiopathic osteoarthritis or posttraumatic arthritis had a higher risk of re-arthrodesis than patients with rheumatoid arthritis. We could not find that the risk of re-arthrodesis was associated with sex. Interpretation - In Sweden, the re-arthrodesis risk varied by primary technique and was especially high after arthroscopic surgery. Reasons are unknown but poor surgical technique and/or surgeon inexperience may contribute, as may patient selection.

Good outcome scores and high satisfaction rate after primary total ankle replacement.

Background and purpose - Total ankle replacement (TAR) is gaining popularity for treatment of end-stage ankle arthritis. Large patient-centered outcome studies are, however, few. Here, we report data from the Swedish Ankle Registry. Patients and methods - We examined outcomes after primary TAR in patients from the Swedish Ankle Registry using PROMs (Patient Reported Outcome Measures; generic: EQ-5D and SF-36, region specific: SEFAS (Self-Reported Foot and Ankle Score), and a question on satisfaction). We included 241 patients registered with primary TAR between 2008 and 2016 and who completed PROMs preoperatively and postoperatively up to 24 months. We evaluated changes in PROMs following surgery and estimated effects of age, diagnosis, prosthetic design, and preoperative functional score on the outcomes. Results - All absolute scores improved from preoperative to 24 months after surgery (p ≤ 0.001). 71% of the patients were satisfied or very satisfied at the latest follow-up and 12% dissatisfied or very dissatisfied. Postoperative SEFAS correlated with age (r = 0.2, p = 0.01) and preoperative SEFAS (r = 0.3, p < 0.001), as did patient satisfaction (r = -0.2; p ≤ 0.03). Postoperative SEFAS and EQ-5D were similar between different diagnoses or prosthetic designs. Preoperative SF-36 was associated with diagnosis (p ≤ 0.03), postoperative SF-36 with age (r = 0.2, p = 0.01) and diagnosis (p < 0.03). Interpretation - We found statistically and clinically significant improvements in patient-reported outcomes following TAR surgery. The postoperative region-specific SEFAS was positively associated with older age. Prosthetic design seemed not to influence patient-reported outcome, whereas diagnosis partly did. Studies with longer follow-up are necessary to establish the long-term outcome of TAR and to elucidate whether short- and mid-term outcomes may predict implant failure.

Risk factors for low back pain and sciatica in elderly men-the MrOS Sweden study.

Introduction: The aim of this study was to identify whether factors beyond anatomical abnormalities are associated with low back pain (LBP) and LBP with sciatica (SCI) in older men. Material and Methods: Mister Osteoporosis Sweden includes 3,014 men aged 69­81 years. They answered questionnaires on lifestyle and whether they had experienced LBP and SCI during the preceding 12 months. About 3,007 men answered the back pain (BP) questions, 258 reported BP without specified region. We identified 1,388 with no BP, 1,361 with any LBP (regardless of SCI), 1,074 of those with LBP also indicated if they had experienced LBP (n = 615), LBP+SCI (n = 459). Results: About 49% of those with LBP and 54% of those with LBP+SCI rated their health as poor/very poor (P < 0.001). Men with any LBP to a greater extent than those without BP had poor self-estimated health, depressive symptoms, dizziness, fall tendency, serious comorbidity (diabetes, stroke, coronary heart disease, pulmonary disease and/or cancer) (all P < 0.001), foreign background, were smokers (all P < 0.01), had low physical activity and used walking aids (all P < 0.05). Men with LBP+SCI to a greater extent than those with LBP had lower education, lower self-estimated health, comorbidity, dizziness and used walking aids (all P < 0.001). Conclusions: In older men with LBP and SCI, anatomical abnormalities such as vertebral fractures, metastases, central or lateral spinal stenosis or degenerative conditions may only in part explain prevalent symptoms and disability. Social and lifestyle factors must also be evaluated since they are associated not only with unspecific LBP but also with LBP with SCI.

Low Testosterone, but Not Estradiol, Is Associated With Incident Falls in Older Men: The International MrOS Study.

Fracture risk is determined by bone strength and the risk of falls. The relationship between serum sex steroids and bone strength parameters in men is well known, whereas the predictive value of sex steroids for falls is less studied. The aim of this study was to assess the associations between serum testosterone (T) and estradiol (E2) and the likelihood of falls. Older men (aged ≥65 years) from the United States (n = 1919), Sweden (n = 2495), and Hong Kong (n = 1469) participating in the Osteoporotic Fractures in Men Study had baseline T and E2 analyzed by mass spectrometry. Bioavailable (Bio) levels were calculated using mass action equations. Incident falls were ascertained every 4 months during a mean follow-up of 5.7 years. Associations between sex steroids and falls were estimated by generalized estimating equations. Fall rate was highest in the US and lowest in Hong Kong (US 0.50, Sweden 0.31, Hong Kong 0.12 fall reports/person/year). In the combined cohort of 5883 men, total T (odds ratio [OR] per SD increase = 0.88, 95% confidence interval [CI] 0.86-0.91) and BioT (OR = 0.86, 95% CI 0.83-0.88) were associated with incident falls in models adjusted for age and prevalent falls. These associations were only slightly attenuated after simultaneous adjustment for physical performance variables (total T: OR = 0.94, 95% CI 0.91-0.96; BioT: OR = 0.91, 95% CI 0.89-0.94). E2, BioE2, and sex hormone-binding globulin (SHBG) were not significantly associated with falls. Analyses in the individual cohorts showed that both total T and BioT were associated with falls in MrOS US and Sweden. No association was found in MrOS Hong Kong, and this may be attributable to environmental factors rather than ethnic differences because total T and BioT predicted falls in MrOS US Asians. In conclusion, low total T and BioT levels, but not E2 or SHBG, are associated with increased falls in older men. © 2017 American Society for Bone and Mineral Research.