No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial.

BACKGROUND: The need for operative treatment of acute acromioclavicular (AC) joint dislocation is unclear. The purpose of this randomized controlled trial was to compare the outcomes after operative treatment with a hook plate with the outcomes after nonoperative treatment of acute Rockwood type III and type V AC joint dislocations separately. METHODS: The inclusion criteria were patients aged 18-65 years with an acute type III or type V AC joint dislocation with the availability to start treatment within 3 weeks after trauma. All patients received the same standardized outpatient rehabilitation protocol and were followed up for 24 months. Assessments were based on radiographs, clinical examination findings, and questionnaires. The primary outcome was the Constant score (CS). The secondary outcomes were as follows: Subjective Shoulder Value (SSV), QuickDASH score (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire), shoulder pain at rest and during movement rated using a visual analog scale, EQ-5D (European Quality of Life 5 Dimensions) score, patient satisfaction, cosmesis, complications, and adverse events. The 4 groups were compared using 1-way analysis of variance and intention to treat. RESULTS: The included patients (N = 124) (mean age, 40 years [range, 18-64 years]; 91% male patients) were randomized, stratified by type, to nonoperative treatment (type III, n = 33; type V, n = 30) or operative treatment with a hook plate (type III, n = 30; type V, n = 31) at a single center. Three patients randomized to physiotherapy dropped out before any follow-up measures, leaving 121 patients in the study. Complete clinical follow-up data were obtained from 118 patients at 24 months. At 3 months, patients in both nonoperatively treated groups had a significantly better mean CS, SSV, and QuickDASH score and had less pain at rest and during movement compared with patients treated operatively. At 6, 12, and 24 months, there were no significant differences in the CS, SSV, QuickDASH score, pain, or EQ-5D score between the groups regardless of intervention. At 24 months, the mean CS was 88 for nonoperatively treated type III patients vs. 91 for operatively treated type III patients and was 90 vs. 91 for type V patients (P = .477). At final follow-up, patients had regained 97% of the mean CS comparing the uninjured and injured shoulders and 86% of the patients rated the result as excellent or good. Eleven patients assigned to nonoperative treatment (18%, 6 type III and 5 type V) underwent surgery within 19 months. CONCLUSIONS: Both the nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months, and operative treatment did not lead to better outcomes compared with nonoperative treatment. In conclusion, our study does not support surgery with a hook plate in patients with acute Rockwood type III or type V AC joint dislocations.

Changing caring behaviours in rehabilitation after a hip fracture - A tool for empowerment?

Different rehabilitation programs after surgery have been presented to improve the outcome for patients with a hip fracture. Empowerment has been suggested as useful, but requires a change in the caring behaviours of health professionals. The aim with this study was to evaluate if training and supervision of the nursing staff could alter caring behaviours. A case-control study of nursing staff treating hip fracture patients was performed at a hospital with two sites. Training and supervision was given to the nursing staff at the intervention site. The intervention focused on creating positive care interaction by using eight guidelines. The evaluation was performed with recordings of a constructed caring situation before training, and observations of care situations at the ward before and after intervention. The results showed no differences at baseline between the two sites in the caring behaviours. After intervention, significant effects of caring behaviours were seen in seven out of eight guidelines, the effect sizes ranged from medium to large. The findings indicate that the nursing staff can change caring behaviours and facilitate the empowerment of patients with a hip fracture.

Low bone mineral density and fat-free mass in younger patients with a femoral neck fracture.

BACKGROUND: Reduced bone mineral density (BMD) together with muscle wasting and dysfunction, that is sarcopenia, emerges as a risk factor for hip fracture. The aim of this study was to examine body composition and BMD and their relationship with trauma mechanisms in young and middle-aged patients with femoral neck fracture. MATERIALS AND METHODS: Altogether, 185 patients with femoral neck fracture aged 20-69 were included. BMD, body composition and fat-free mass index (FFMI) were determined by dual-X-ray absorptiometry (DXA), and trauma mechanisms were registered. RESULTS: Ninety per cent of the whole study population had a femoral neck BMD below the mean for age. In the young patients (< 50 years), 27% had a Z-score of BMD ≤ -2 SD. More than half of the middle-aged patients (50-69 years) had osteopenia, that is T-score -1 to -2.5, and 35% had osteoporosis, that is T-score < -2.5, at the femoral neck. Patients with low-energy trauma, sport injury or high-energy trauma had a median standardised BMD of 0.702, 0.740 vs. 0.803 g/cm(2) (P = 0.03), and a median FFMI of 15.9, 17.7 vs. 17.5 kg/m(2) (P < 0.001), respectively. FFMI < 10th percentile of an age- and gender-matched reference population was observed in one-third. CONCLUSIONS: A majority had low BMD at the femoral neck, and one-third had reduced FFMI (i.e. sarcopenia). Patients with fracture following low-energy trauma had significantly lower femoral neck BMD and FFMI than patients with other trauma mechanisms. DXA examination of both BMD and body composition could be of value especially in those with low-energy trauma.

Effects of protein-rich nutritional supplementation and bisphosphonates on body composition, handgrip strength and health-related quality of life after hip fracture: a 12-month randomized controlled study.

BACKGROUND: The catabolic state that follows hip fracture contributes to loss of muscle mass and strength, that is sarcopenia, which impacts functional ability and health-related quality of life. Measures to prevent such long-term postoperative consequences are of important concern. The aim of this study was to evaluate the combined effects of protein-rich nutritional supplementation and bisphosphonate on body composition, handgrip strength and health-related quality of life following hip fracture. METHODS: The study included 79 men and women with hip fracture, mean age 79 years (SD 9), without severe cognitive impairment, who were ambulatory and living independently before fracture. Patients were randomized postoperatively to receive liquid supplementation that provided 40 g of protein and 600 kcal daily for six months after the fracture, in addition to bisphosphonates once weekly for 12 months (group N, n = 26), or bisphosphonates alone once weekly for 12 months (group B, n = 28). All patients, including the controls (group C, n = 25) received calcium 1 g and vitamin D3 800 IU daily. Body composition as measured by dual-energy X-ray absorptiometry (DXA), handgrip strength (HGS) and health-related quality of life (HRQoL) were registered at baseline, six and 12 months postoperatively. RESULTS: There were no differences among the groups regarding change in fat-free mass index (FFMI), HGS, or HRQoL during the study year. Intra-group analyses showed improvement of HGS between baseline and six months in the N group (P = 0.04). HRQoL decreased during the first year in the C and B groups (P = 0.03 and P = 0.01, respectively) but not in the nutritional supplementation N group (P = 0.22). CONCLUSIONS: Protein-rich nutritional supplementation was unable to preserve FFMI more effectively than vitamin D and calcium alone, or combined with bisphosphonate, in this relatively healthy group of hip fracture patients. However, trends toward positive effects on both HGS and HRQoL were observed following nutritional supplementation. TRIAL REGISTRATION: Clinicaltrials.gov NCT01950169 (Date of registration 23 Sept 2013).

Power to the patient: care tracks and empowerment a recipe for improving rehabilitation for hip fracture patients.

BACKGROUND/AIM: New surgical procedures, early operation and medical optimisation in patients with hip fracture have shown positive results on length of hospital stay. Our aims were to investigate whether patient empowerment along with an individually designed, postoperative rehabilitation programme could reduce length of hospital stay and whether the patients would have better chances to return to their previous living. DESIGN/METHOD: Patients were recruited during a 12-month period 2009-2010, with an intervention group treated with an individually designed, postoperative rehabilitation programme and a control group treated in a traditional way according to the hospitals routines. Final assessment was performed 4 month after surgery. The postoperative programme for the intervention group consisted of four standardised care tracks adapted individually for the patients. Assessments of Activity of Daily Living, American Society of Anesthesiologists classification of medical disease status and Short Portable Mental Status Questionnaire and living conditions were used to determine which care track was most appropriate. The patients were cared for with focus of empowerment in their rehabilitation. RESULTS: The study involved 503 hip fracture patients, 285 patients in the intervention group and 218 patients in the control group. The mean length of stay was 4 days shorter in the intervention group than in the control group (p = 0.04). Varied only to a small extent between the age groups in the intervention group and was greater between the age groups in the control. Patients in the intervention group returned to their previous living in 90% compared with 80% in the control group (p < 0.05). There were no significant differences between the age groups. CONCLUSION: Patient empowerment administrated by specially trained nursing staff and with specialised, tailor-made rehabilitation programme may be of benefit in helping patients to a shorter hospital stay and to return to their previous living.

Pathological subtrochanteric fractures in 194 patients: a comparison of outcome after surgical treatment of pathological and non-pathological fractures.

BACKGROUND: The surgical treatment of pathological subtrochanteric fractures has been associated with technical difficulties and frequent failures. We analyzed survival, risk factors for death, and outcome after surgical treatment. METHODS: The study group consisted of 194 patients with pathological subtrochanteric femur fractures operated during 1999-2009. Cox multiple-regression analysis was performed to study risk factors and results were expressed as hazard ratios (HR). We included a control group with non-pathological subtrochanteric fractures (n = 87) for comparison. RESULTS: The median age at surgery was 68 (29-96) years in the study group and 82 (66-101) in the controls. The 1-year survival rate after surgery was 33% (95% CI: 26-40) in the study group and 85% (79-93) in the controls. In the study group, the risk of death after surgery was increased for patients ≥65 years of age (HR 1.5, 95% CI: 1.1-2.1), with a moderate (HR 2.2, 1.5-3.4) and poor (HR 2.9, 1.6-5.2) Karnofsky score, with visceral metastases (HR 1.6, 1.1-2.3), and perioperative hemoglobin levels <100 g/L (HR 2.2, 1.3-3.7). In patients with pathological fractures, there was no statistically significant difference concerning reoperation rates comparing intramedullary nails (9%) with endoprostheses (6%; P = 0.3). CONCLUSIONS: Surgery for pathological subtrochanteric femur fractures is a relatively safe and effective procedure.

Risk factors for osteoporosis are common in young and middle-aged patients with femoral neck fractures regardless of trauma mechanism.

BACKGROUND AND PURPOSE: There have been few prospective studies examining young and middle-aged patients with hip fracture. We therefore investigated background data, risk factors, and the trauma mechanism in young and middle-aged patients with femoral neck fracture. PATIENTS AND METHODS: 185 patients, 27 young (20-49 years old) and 158 middle-aged (50-69 years old) were prospectively included in a multicenter study lasting 3 years. Background data and risk factors for osteoporosis and fracture were obtained, and the type of injury was classified as low-energy trauma, high-energy trauma, or sports injury. RESULTS: In the young age group, the fracture occurred because of low-energy trauma in two-fifths of patients and because of sport injury in two-fifths of patients. The rest occurred because of high-energy trauma. The corresponding proportions for the middle-aged group were four-fifths, one tenth, and one tenth (p < 0.001). There was a higher proportion of men (19/27) in the young group than in the middle-aged group (69/158) (p = 0.001). One fifth of the young patients were smokers as compared to two-fifths in the middle-age group (p = 0.04). One quarter of the patients reported high-volume alcohol drinking, with no difference between the two groups. Furthermore, three-quarters of the young patients and four-fifths of the middle-aged patients had one or more risk factors for osteoporosis and fracture. INTERPRETATION: A minority of patients in each age group had high-energy trauma as the cause of their femoral neck fracture. Lifestyle factors and other non-trauma-related risk factors appear to have been important contributors to the occurrence of femoral neck fracture in both age groups.

The Ward Round: Patients' Perceptions of a Patient-Centered Approach and Their Suggestions for Improved Participation.

Purpose: To explore, through a learning activity for healthcare students, how patients perceived the ward round and its patient-centered approach. Patients and Methods: Patients admitted for elective orthopedic surgery were invited to participate in the study, which involved answering a survey comprising seven intersectional questions and eight free text questions. In addition, medical and nursing students did semi-structured interviews with the patients, covering the same free text questions. Twenty-three patients answered the survey, of whom fifteen also completed the interviews. The results from the interviews were explored using a thematic content analysis. Results: Forty-three percent (10/23) of the patients strongly agreed or agreed that their knowledge of patient-centered ward round was sufficient to be able to participate actively, and thirty percent (7/23) indicated they had good knowledge of the laws and regulations governing the care of patients. Most of the patients felt satisfied with how their own and their relatives' experiences were taken into account. The categories information and to be listened to were mentioned repeatedly by patients as priorities for patient-centered ward rounds. The interview analysis revealed four main categories: preparation, communication, organization, and safety as important and in need of improvement. Conclusion: Less than half of the patients surveyed felt they could participate in the ward round, which indicates that there is an opportunity for improvement and development. Better information and communication about legal rights, as well as about the structure and content of the ward round, could be valuable to patients before admission. It is also important to find a way for patients' individual wishes to be more fully and easily conveyed to medical staff. Creating a more tailor-made ward round for each patient and fulfilling a patient-centered approach will likely entail a substantial organizational and mental shift.

Transfer of anatomy during surgical clerkships: an exploratory study of a student-staff partnership.

Objectives: This qualitative study aims to explore how fourth-year medical students on the surgery course perceived a clinical anatomy workshop organised by near-peer student teachers in partnership with faculty. Methods: Forty-seven medical students participated in a workshop on clinical anatomy in the dissection laboratory. A voluntary response sampling method was used. The students' perceptions of the workshop were explored through a thematic content analysis of transcribed, semi-structured group interviews and written comments. Results: A majority of the students had not revisited the dissection laboratory since their second year, and all students described the workshop as a unique opportunity to vertically integrate anatomical knowledge. Four main themes were identified as most valuable for the students' learning experience, namely that the workshop 1) was taught by knowledgeable and friendly near-peer tutors (NPTs), 2) consisted of highly relevant anatomical content, 3) offered a hands-on experience of cadavers in the dissection laboratory, and 4) was taught in a focused session in the middle of the surgery course. Conclusions:  This study shows how hands-on workshops in clinical anatomy, developed in student-staff partnerships and taught by NPTs, can enable senior medical students to recall and vertically integrate anatomical knowledge during surgical clerkships. The results have implications for curriculum design, giving voice to senior students' wishes for spaced repetition and vertical integration of pre-clinical anatomy knowledge during their clinical training. Moreover, this study may inspire other students and faculty to develop similar near-peer teaching activities through student-staff partnerships.

Function, sarcopenia and osteoporosis 10 years after a femoral neck fracture in patients younger than 70 years.

BACKGROUND AND PURPOSE: A femoral neck fracture (FNF) may have long-term effects on the patient's function, also in patients younger than 70 years. These long-term effects are not well described, since most studies have short follow-ups. The aim of this study was to investigate clinical outcome by performance-based functional tests, hand grip strength, and hip function in different subgroups. The secondary aim was to study surgical complications, bone mineral density (BMD) and occurrence of sarcopenia 10 years after a FNF. PATIENTS AND METHODS: A prospective multicenter study with a 10-year follow-up of patients aged 20-69 years with a FNF treated with internal fixation (IF). Five-times sit-to-stand test (5TSST), 4-m walking speed test, hand grip strength (HGS) and Harris Hip Score (HHS) were performed. A radiographic examination of the hip was performed and re-operations were registered. Bone mineral density (BMD) at the hip, spine and total body composition were assessed with dual energy x-ray absorptiometry (DXA). Present sarcopenia was determined by the combination of reduced functional performance and low fat-free mass index (FFMI). RESULTS: A total of 58 patients were included. 5TSTS was normal in 45% of the patients and old age was associated with poorer performance (p<0.001). 76% of the study population had a normal speed gait and likewise, old age (p = 0.005) and walking aids (p = 0.001) were associated with poor performance. HGS was normal in 82% of the men and 64% of the women. HHS showed that 85% had a good/excellent function. A major re-operation was performed in 34% of the patients with displaced FNF and in 20% of patients with non-displaced FNF. 74% displayed osteopenia and 12% osteoporosis. 17% of the men and 38% of the women had sarcopenia. INTERPRETATION: The majority of patients less than 70 years of age with a FNF treated with IF, had normal functional tests, muscle strength and a good hip function ten years post-operatively. However, one in ten had osteoporosis, and one third was sarcopenic which indicate the importance of encouraging regular muscle preserving resistance training after hip fracture.

Health related quality of life and mortality 10 years after a femoral neck fracture in patients younger than 70 years.

BACKGROUND AND PURPOSE: A femoral neck fracture (FNF) may have long term effects on the patient's health related quality of life (HRQoL) and mortality, especially in patients younger than 70 years. These long-term effects are unknown since most studies have a short follow-up. The aim of this study was to investigate self-assessed hip function, HRQoL and factors associated with 10-years mortality after a FNF. PATIENTS AND METHODS: A prospective multicenter study with a 10-year follow-up of patients aged 20-69 years with a displaced and non-displaced FNF treated with closed reduction and internal fixation. The self-administered questionnaires EuroQol 5 Dimension (EQ-5D) and Hip Disability Outcome Score (HOOS) were used. Results of EQ-5D and HOOS was compared to sex and age matched general population data of Sweden. All patients that were deceased had their death date recorded. Factors associated with mortality were assessed by regression analysis of the baseline data including age, gender, harmful alcohol consumption according to AUDIT, co-morbidity measured by ASA-grade, body mass index, osteoporosis measured by dual energy x-ray absorptiometry (DXA) and smoking. Prevalence of co-morbidities and smoking was compared to general population data. RESULTS: From initial 182 included patients, 55 were deceased at 10-year follow-up, 4 were deregistered from public record and 35 declined participations. A total of 88 patients participated through self-administrated questionnaires. There were no significant differences in HOOS between gender and fracture type and the results were equivalent to general population data. The EQ-5D continued to improve compared to a 24-month follow-up (p = 0.006) but did not recover to pre-fracture level (p<0.001) though it was equivalent to general population data. Higher age, co-morbidity, osteoporosis and smoking were associated with increased mortality within 10 years after the fracture and the prevalence of co-morbidity and smoking was higher than the general population. INTERPRETATION: Those patients who had survived 10 years after a FNF treated with CRIF had a HRQoL and hip function equivalent to age and sex matched general population of Sweden. However, a third of these relatively young patients had deceased 10 years after the hip fracture and they were more compromised than the general population.

Prediction of mortality in elderly patients with hip fractures: a two-year prospective study of 1,944 patients.

BACKGROUND: Hip fracture patients are reported to have an increased mortality rate compared to the general population. In order to be able to reduce the morbidity and mortality after a hip fracture, our efforts to identify the patients at risk already upon admission to the hospital need to be increased. For such a risk assessment, robust, validated, and reproducible criteria are mandatory. OBJECTIVE: To determine preoperative factors associated with mortality and to evaluate the combined use of the American Society of Anesthesiologists (ASA) and the Short Portable Mental Status Questionnaire (SPMSQ) to identify patients with an increased mortality rate and to create a predictive model to assess the mortality risk after hip fracture surgery. METHODS: A total of 1,944 consecutive patients aged 66 years or older admitted for a hip fracture were included in a prospective cohort study with a 24-month follow-up. The patients were assessed with regard to gender, age, type of hip fracture, smoking habits, comorbidities, general physical health according to the ASA classification, and cognitive function according to the SPMSQ. A higher ASA score indicates an increasingly severe systemic disease and a lower SPMSQ score indicates an increasingly severe cognitive dysfunction. We used Cox proportional hazard models and classification trees to identify the factors associated with mortality. The predictive model was created based on factors that were significantly associated with death and all readily accessible upon admission. RESULTS: The mortality rate during the acute hospitalization period was 4%, at 4 months 16%, and at 24 months 38%. The most prominent factors associated with mortality were high ASA scores, low SPMSQ scores, high age and male gender. The SPMSQ score provided additional information about the survival time, compared to when the ASA score was used alone. CONCLUSION: The combined use of the ASA classification for assessing physical health and the SPMSQ for assessing cognitive function effectively identified hip fracture patients with an increased mortality rate. We present a predictive model including age, gender, ASA, and SPMSQ that can be used to assess the mortality risk after hip fracture surgery.

Good overall morbidity prediction with the POSSUM scoring system in patients having a total hip or knee replacement - a prospective study in 227 patients.

PURPOSE: The Physiological and Operation Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and P (Portsmouth)-POSSUM predict the risks of complications and mortality 30 days after surgery. The purpose of this study was to evaluate the POSSUM and P-POSSUM scoring systems in patients who underwent surgery for a total hip or knee replacement. PATIENTS AND METHODS: A total of 227 patients with an elective primary total hip or knee replacement were included. The predicted postoperative morbidity was analyzed in these patients and compared with the observed value 30 days after surgery. Logistic regression analysis was used to assess the correlation of variables and outcome. RESULTS: The number of patients undergoing total hip or knee replacement was equally distributed with a mean age of 66.4±12.5 years; 57% of patients were females. Postoperative complications occurred in 49 patients, and POSSUM predicted 49 cases with an observed-over-expected ratio of 1.0. The average total POSSUM score was 27.4±4.4 in patients with complications and 26.8±3.5 in patients without complications (P=0.340). Wound infection (n=18), urinary tract infection (n=7), and pulmonary embolus (n=5) were the most common complications. The operation magnitude variable had the highest mean POSSUM score making it the most relevant variable. Age and blood loss and echocardiogram had the largest variance among the assessed variables. CONCLUSION: POSSUM accurately predicted morbidities in patients undergoing elective primary total hip or knee replacement. The risk for wound infection, urinary retention, and pulmonary embolus should be considered during hospitalization. The computerized POSSUM system provides case-mix-adjusted morbidity predictions for groups and, hence, serves as a useful tool for surgical audits and large-scale benchmarking.

Low BMD and high alcohol consumption predict a major re-operation in patients younger than 70 years of age with a displaced femoral neck fracture-A two -year follow up study in 120 patients.

BACKGROUND AND PURPOSE: The recommended treatment of displaced femoral neck fractures (FNF) in patients younger than 70 years of age is fracture reduction and internal fixation (IF). The incidence of re-operation due to nonunion (NU) or avascular necrosis (AVN) has been reported to be between 20-30%. Knowledge of possible predisposing factors needs to be elucidated. The primary aim of this study was to identify factors associated with a major re-operation due to NU or AVN in patients <70 years with a displaced FNF treated with IF. PATIENTS AND METHODS: 128 patients, 20-69 years with a FNF treated with IF. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Logistic regression analysis was used to identify factors associated with re-operation due to NU or AVN. RESULTS: The re-operation rate due to NU or AVN was 6%, 16% and 28% at 4, 12 and 24 months respectively. Patients with low BMD was more likely to be re-operated than those with normal BMD, OR 5.5, CI (95%) 1.15-26.8, and those with a high alcohol consumption had 3.2 times higher odds to be re-operated due to NU or AVN, CI (95%) 1.16-8.76. INTERPRETATION: In more than two thirds (83/120) of the patients the fracture healed after one operation. Moreover, a low BMD and high alcohol consumption were related to a major re-operation. These results suggest that only age as a sole variable for choosing the type of surgical treatment may not be rational.

Operative Repair of Medial Patellofemoral Ligament Injury Versus Knee Brace in Children With an Acute First-Time Traumatic Patellar Dislocation: A Randomized Controlled Trial.

BACKGROUND: A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment. PURPOSE: (1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years. RESULTS: The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth <3 mm) had the highest odds ratio for redislocations (2.35 [95% CI, 0.69-8.03]), with no significant association between APIFs and a redislocation. CONCLUSION: Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations. Registration: ISRCTN 39959729 (Current Controlled Trials).

Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate.

OBJECTIVE: To compare outcome between the proximal femoral nail (PFN) and the Medoff sliding plate (MSP) in patients with unstable trochanteric or subtrochanteric fractures. METHODS: This was a consecutive prospective randomized clinical study. In all, 203 patients admitted to two university hospitals with an unstable trochanteric or a subtrochanteric fracture type were included. Surgery was performed with a short intramedullary nail or a dual-sliding plate device. Follow up visits occurred at 6 weeks, 4 months, and 12 months. Functional outcome was measured by walking ability, rising from a chair, curb test, and additional assessments of abductor strength, pain, living conditions, and complications. RESULTS: The ability to walk 15 m at 6 weeks was significantly better in the PFN group compared to the MSP group with an odds ratio 2.2 (P = 0.04, 95% confidence limits 1.03-4.67). No statistical difference in walking ability could be found between trochanteric and subtrochanteric fractures. The major complication rate (8% in the PFN group and 4% in the MSP group) did not differ statistically (P = 0.50) but reoperations were more frequent in the PFN group (9%) compared to the MSP group (1%; P < 0.02). CONCLUSIONS: There were no major differences in functional outcome or major complications between the treatment groups. Reasons other than the operated fracture seem to be equally important in determining the long-term functional ability of the patients in our study. An advantage with the MSP was the lower reoperation rate.

Good functional outcome but not regained health related quality of life in the majority of 20-69 years old patients with femoral neck fracture treated with internal fixation: A prospective 2-year follow-up study of 182 patients.

BACKGROUND AND PURPOSE: Prospective studies on patient related outcome in patients <70years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20-69years old patients with a FNF treated with internal fixation. PATIENTS AND METHODS: 182 patients, 20-69years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations. RESULTS: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p=0.15). Of the patients with displaced fracture (n=120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n=50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p<0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p<0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p<0.001). INTERPRETATION: Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.

Good responsiveness with EuroQol 5-Dimension questionnaire and Short Form (36) Health Survey in 20-69 years old patients with a femoral neck fracture: A 2-year prospective follow-up study in 182 patients.

BACKGROUND: EQ-5D and SF-36 are two questionnaires used to measure health related quality of life (HRQoL). The responsiveness of these instruments has previously been evaluated in elderly populations with hip fracture but not in a younger population. The purpose was to evaluate the responsiveness of SF-36 and EQ-5D in a younger population with femoral neck fracture. METHODS: 182 patients aged 20-69 were consecutively included. HRQoL was measured by EQ-5D and SF-36 at 4, 12 and 24 months. Pain and function were measured by Harris Hip Score (HHS) on the same occasions. The responsiveness of EQ-5D and SF-36 was evaluated by calculation of two effect sizes; standardized effect size (SES) and standardized response mean (SRM), and by analysing how changes in score correlated to changes in function and subjective state of health. External responsiveness was also evaluated by calculating receiver operating characteristic curve and area under the curve. RESULTS: SES was large at four months for both EQ-5D and SF-36 (1.09 and 0.83 respectively) and moderate at the 12- and 24-month follow-ups. The correlation between changes (4-24 months) in HHS and changes in HRQoL were 0.44 for EQ-5D and 0.37 for SF-36. EQ-5D and SF-36 were both more sensitive than HHS in their ability to predict subjective improvements after a hip fracture. CONCLUSIONS: The effect sizes and the ability to follow and predict the external standard indicates that both EQ-5D and SF-36 have good internal and external responsiveness in this younger population with femoral neck fracture. The generic HRQoL questionnaires were superior to a hip-specific instrument in predicting the patients' subjective feelings of an improved state of health. EQ-5D is simple to administer and shows similar responsiveness as SF-36 and may be sufficient to use as an outcome measure in clinical trials.

Medial Patellofemoral Ligament Injuries in Children With First-Time Lateral Patellar Dislocations: A Magnetic Resonance Imaging and Arthroscopic Study.

BACKGROUND: A lateral patellar dislocation (LPD) is the most common knee injury in children with traumatic knee hemarthrosis. The medial patellofemoral ligament (MPFL), the important passive stabilizer against LPDs, is injured in more than 90% of cases. The MPFL injury pattern is most often defined in adults or in mixed-age populations. The injury pattern in the skeletally immature patient may be different. PURPOSE: To describe MPFL injuries in the skeletally immature patient by magnetic resonance imaging (MRI), and to compare the results with the injury pattern found at arthroscopic surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a prospective series of patients aged 9 to 14 years with acute, first-time traumatic LPDs in whom clinical examinations, radiographs, MRI, and arthroscopic surgery were performed within 2 weeks from the index injury. The MPFL injury was divided into 3 different groups according to the location: patellar site, femoral site, or multifocal. The MPFL injury site was confirmed on MRI by soft tissue edema. The length of the MPFL injury at the patellar site was measured at arthroscopic surgery, and those ≥2 cm were defined as total ruptures. RESULTS: A total of 74 patients (40 girls and 34 boys; mean age, 13.1 years) were included; 73 patients (99%) had an MPFL injury according to MRI and arthroscopic surgery. The MRI scans showed an isolated MPFL injury at the patellar attachment site in 44 of 74 patients (60%), a multifocal injury in 26 patients (35%), an injury at the femoral site in 3 patients (4%), and no injury in 1 patient (1%). Arthroscopic surgery disclosed an isolated MPFL injury at the patellar site in 60 of 74 patients (81%) and a multifocal injury in 13 patients (18%); the MPFL injury at the patellar site was a total rupture in 49 patients (66%). Edema at the patellar attachment site on MRI was proven to be an MPFL rupture at the same site at arthroscopic surgery in 99% of the patients. A patellar-based injury, isolated or as part of a multifocal injury, was present on MRI in 95% (n = 70) of the patients, with a false-negative rate of 5% (n = 4) of patients compared with arthroscopic surgery. CONCLUSION: Skeletally immature children are more prone to sustaining an MPFL injury at the patellar attachment site. Arthroscopic surgery and MRI complement each other in the investigation of MPFL injuries.

Sex effects on short-term complications after hip fracture: a prospective cohort study.

OBJECTIVES: To evaluate potential sex differences and other factors associated with complications within 4 months after a hip fracture. METHODS: A total of 1,915 patients ≥65 years (480 men) with hip fracture were consecutively included in a prospective multicenter cohort study. A review of medical records and patient interviews according to a study protocol based on the Standardized Audit of Hip Fractures in Europe (SAHFE, RIKSHÖFT) was performed. Sex differences in comorbidity according to the American Society of Anesthesiologists score and complications 4 months after a hip fracture were registered. Multivariate logistic regression analysis was performed to identify factors related to complications. RESULTS: Male sex was associated with worse general health according to the American Society of Anesthesiologists classification (P=0.005) and with more comorbidities (P<0.001). Male sex emerged as a risk factor for developing pneumonia (P<0.001), and additionally, 18% of the men suffered from cardiac complications compared with 13% of the females (P=0.018). Female sex was predisposed for urinary tract infections, 30% vs 23% in males (P=0.001). Mortality was higher in the male vs female group, both within 30 days (15% vs 10%, P=0.001) and at 4 months (24% vs 14%, P=0.001). Conditions associated with pneumonia were male sex, pulmonary disease, and cognitive impairment. Cardiac complications were associated with delayed surgery and cardiovascular and pulmonary disease. CONCLUSION: Before surgery, men with hip fracture already have a poorer health status and higher comorbidity rate than women, thus resulting in a twofold increased risk of pneumonia. Cognitive dysfunction and pulmonary disease contributed to pneumonia in men. Delayed surgery seems to increase the risk for cardiac complications. It is important to consider the sex perspective early on together with cardiopulmonary comorbidity and cognitive dysfunction to be able to counteract serious complications that may lead to death.