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.

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.

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.

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.

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.

The effectiveness of low-load Blood flow restriction Exercise in patients with an acute Achilles tendon rupture treated Non-surgically (BEAN): Protocol for a randomized controlled trial.

BACKGROUND: Blood flow restriction exercise (BFRE) has been proposed as a viable method for preserving muscle mass and function after an injury during periods of load restrictions such as after an acute Achilles tendon rupture. However, its effectiveness and safety in patients with an Achilles tendon rupture have yet to be evaluated in a randomized trial. OBJECTIVES: First, to investigate the effectiveness of early initiated BFRE in patients with non-surgically treated acute Achilles tendon rupture. Second, to evaluate whether it is better to apply BFRE in the beginning (1-12 weeks) or later (13-24 weeks) in the rehabilitation period. METHODS: This is an assessor-blinded, randomized, controlled multicenter trial with patients assigned in a 1:1 ratio to two parallel groups, that either receive BFRE in weeks 1-12 followed by usual care in weeks 13-24, or receive usual care in weeks 1-12 followed by BFRE in weeks 13-24. The BFRE program is performed three times weekly on the injured leg at 80 % of the pressure required to fully restrict the arterial blood flow. Post-intervention tests are conducted in week 13, comparing early BFRE with usual care, and in week 25, comparing early BFRE with late BFRE. At the 13-week evaluation, the primary outcome is the Single-Leg Heel-Rise test which assesses the patient's ability to raise the heel of the injured leg a minimum of 2 cm. At the 25-week evaluation, the primary outcome is the Achilles tendon Total Rupture Score which assesses the patient's self-reported symptoms and physical ability.

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.

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.

Computer-Assisted Intramedullary Nailing of Intertrochanteric Fractures Did Not Prevent Tip-Apex Distance Outliers.

Intertrochanteric femoral fractures are commonly treated with intramedullary nails (IMNs). A tip-apex distance (TAD) of more than 20-25 mm is associated with an increased risk of cut-out. The Stryker Adaptive Positioning System (ADAPT) is a computer-assisted navigation system designed to reduce TADs. We aim to assess if the ADAPT reduces the number of outliers with a TAD > 20 mm. All patients with intertrochanteric fractures treated with an IMN between 1 September 2020 and 12 March 2022 were included. Patients were included in three periods: a pre-ADAPT period (55 patients); an ADAPT period (50 patients), where it was compulsory to use the system; and a post-ADAPT period after the discontinuation of the system (59 patients). The TADs and lag screw protrusions beyond the lateral cortex were measured. The median TADs in the three periods were 17.0 mm (8-31 mm), 15.5 mm (9-30 mm), and 18.0 mm (11-32 mm), respectively. The absolute number of outliers with a TAD > 20 mm decreased from 15/55 patients in the pre-ADAPT period to 11/50 patients during the ADAPT period. This observation was not statistically significant, but this is likely due to the lack of power of the present study to show changes of this magnitude. However, our expectation that the ADAPT would diminish outliers markedly or close to zero outliers was not met, as we observed 11/50 = 22% outliers with a TAD > 20 mm when using computer-assisted surgery, i.e., ADAPT and Gamma3 for intertrochanteric fractures. Based on these findings, the use of the ADAPT was discontinued at our level 1 trauma center.

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.

Reoperation for sliding hip screws vs cannulated cancellous screws in femoral neck fractures: A study from the Danish Fracture Database Collaborators.

INTRODUCTION: It is still debated whether to use cannulated cancellous screw (CCS) or sliding hip screw (SHS) implants for femoral neck fracture (FNF) patients but there are no studies large enough to evaluate on smaller differences. The aim were to compare the reoperation and mortality rates of a large cohort of FNF patients above 60 years of age with internal fixation using CCS and SHS implants, with stratification by fracture classification. METHODS: This register study employed prospectively collected data from 2014 to 2018 from the Danish Fracture Database, including 2-year follow-up and data on age, sex, surgery, comorbidity and fracture classification. Reoperation data was retrieved from the Danish National Patient Register. The primary outcome was major reoperation, defined as re-osteosynthesis, conversion to arthroplasty, non-union surgery, Girdlestone procedure or deep infection 1-year post-surgery. Relative risk (RR) for the CCS group compared with the SHS group was estimated using Cox proportional hazards modelling, adjusted for age, sex and comorbidity (including 95% confidence intervals). RESULTS: A total of 2,598 FNFs were included, 1,731 with CCS (67%) and 867 with SHS (33%). The overall 1-year major reoperation rate was 15% with CCS and 13% with SHS, yielding an adjusted RR of 1.10 (0.88; 1.37) for CCS compared to SHS. The adjusted RR was 1.15 (0.77; 1.69) for undisplaced FNF, 1.09 (0.68; 1.75) for displaced FNF and 1.35 (0.94; 1.94) for transcervical FNF, which increased to 1.42 (1.01; 2.00) after 2 years. The minor reoperation rate was higher for CCS (3%) than SHS (1%), yielding an adjusted RR of 2.28 (1.14; 4.51). The adjusted RR for CCS compared to SHS was 0.83 (0.62; 1.12) for 30-day mortality and 0.96 (0.82; 1.14) for 1-year mortality. CONCLUSIONS: We found no difference between CCS and SHS in major reoperation rates; however, for transcervical FNF, CCS was associated with higher reoperation rates. Furthermore, CCS was associated with a higher risk of minor reoperation than SHS. There were no differences in mortality rates.

Preoperative templating in orthopaedic fracture surgery: The past, present and future.

Preoperative planning in orthopaedic fracture surgery corroborates with the goal of establishing the best possible surgical result and ensuring a functioning limb for the patient. From placing sketches on overhead projector paper and measuring lengths from anatomical landmarks, ways of preoperative planning have evolved rapidly over the last 100 years. Today, preoperative planning includes methods such as advanced 3-Dimensional (3D) printed models and software programs incorporating entire libraries of osteosynthesis materials that can be shaped and rotated to fit a patient's specific anatomy. Relevant literature was evaluated to review the development of preoperative templating from the past and present, in order to assess its impact on the future of osteosynthesis.We identified studies on 3D-imaging, computer-assisted systems, and 3D-printed fractured bones and drill guides. The use of some of these systems resulted in a reduction in operation time, blood loss, perioperative fluoroscopy and hospital stay, as well as better placement of osteosynthesis material. Only few studies have identified differences in patient morbidity and mortality. Future techniques of preoperative templating are on the rise and the potential is vast. The cost-effectiveness and usefulness of certain methods need to be evaluated further, but the benefit of preoperative templating has the potential of being revolutionary, with the possibility of radical advances within orthopaedic surgery.

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis.

Background: There are several studies on nonunion, but there are no systematic overviews of the current evidence of risk factors for nonunion. The aim of this study was to systematically review risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures. Methods: Medline, Embase, Scopus, and Cochrane were searched using a search string developed with aid from a scientific librarian. The studies were screened independently by two authors using Covidence. We solely included studies with at least ten nonunions. Eligible study data were extracted, and the studies were critically appraised. We performed random-effects meta-analyses for those risk factors included in five or more studies. PROSPERO registration number: CRD42021235213. Results: Of 11,738 records screened, 30 were eligible, and these included 38,465 patients. Twenty-five studies were eligible for meta-analyses. Nonunion was associated with smoking (odds ratio (OR): 1.7, 95% CI: 1.2-2.4), open fractures (OR: 2.6, 95% CI: 1.8-3.9), diabetes (OR: 1.6, 95% CI: 1.3-2.0), infection (OR: 7.0, 95% CI: 3.2-15.0), obesity (OR: 1.5, 95% CI: 1.1-1.9), increasing Gustilo classification (OR: 2.2, 95% CI: 1.4-3.7), and AO classification (OR: 2.4, 95% CI: 1.5-3.7). The studies were generally assessed to be of poor quality, mainly because of the possible risk of bias due to confounding, unclear outcome measurements, and missing data. Conclusion: Establishing compelling evidence is challenging because the current studies are observational and at risk of bias. We conclude that several risk factors are associated with nonunion following surgically managed, traumatic, diaphyseal fractures and should be included as confounders in future studies.

[Fracture-related infections].

Fracture-related infections (FRI) is a challenging complication with a high risk of devastation outcomes for the patients. Diagnosing FRI is often difficult, and treatment frequently requires the effort of a multidisciplinary team. Recently, an international consensus group of experts from various scientific and medical organisations has published standardised guidelines of diagnosis and treatment. This review provides a summary of the latest studies and the general principles with respect to diagnosis, treatment and aftercare of patients with FRI.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis.

OBJECTIVE: to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM). MATERIALS AND METHODS: Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate. RESULTS: Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures. CONCLUSION: No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.