Increasing but levelling out risk of revision due to infection after total hip arthroplasty: a study on 108,854 primary THAs in the Norwegian Arthroplasty Register from 2005 to 2019.

Background and purpose - Focus on prevention, surveillance, and treatment of infection after total hip arthroplasty (THA) in the last decade has resulted in new knowledge and guidelines. Previous publications have suggested an increased incidence of surgical revisions due to infection after THA. We assessed whether there have been changes in the risk of revision due to deep infection after primary THAs reported to the Norwegian Arthroplasty Register (NAR) over the period 2005-2019.Patients and methods - Primary THAs reported to the NAR from January 1, 2005 to December 31, 2019 were included. Adjusted Cox regression analyses with the first revision due to deep infection after primary THA were performed. We investigated changes in the risk of revision as a function of time of primary THA. Time was stratified into 5-year periods. We studied the whole population of THAs, and the subgroups: all-cemented, all-uncemented, reverse hybrid (cemented cup), and hybrid THAs (cemented stem). In addition, we investigated factors that were associated with the risk of revision, and changes in the time span from primary THA to revision.Results - Of the 108,854 primary THAs that met the inclusion criteria, 1,365 (1.3%) were revised due to deep infection. The risk of revision due to infection, at any time after primary surgery, increased through the period studied. Compared with THAs implanted in 2005-2009, the relative risk of revision due to infection was 1.4 (95% CI 1.2-1.7) for 2010-2014, and 1.6 (1.1-1.9) for 2015-2019. We found an increased risk for all types of implant fixation. Compared to 2005-2009, for all THAs, the risk of revision due to infection 0-30 days postoperatively was 2.2 (1.8-2.8) for 2010-2014 and 2.3 (1.8-2.9) for 2015-2019, 31-90 days postoperatively 1.0 (0.7-1.6) for 2010-2014 and 1.6 (1.0-2.5) for 2015-2019, and finally 91 days-1 year postoperatively 1.1 (0.7-1.8) for 2010-2014 and 1.6 (1.0-2.6) for 2015-2019. From 1 to 5 years postoperatively, the risk of revision due to infection was similar to 2005-2009 for both the subsequent time periodsInterpretation - The risk of revision due to deep infection after THA increased throughout the period 2005-2019, but appears to have levelled out after 2010. The increase was mainly due to an increased risk of early revisions, and may partly have been caused by a change of practice rather than a change in the incidence of infection.

Hip disorders in children and adolescents ­ assessment and treatment of sequelae. / Hoftelidelser hos barn og unge ­ utredning og behandling av senfølger.

The consequences of hip disorders and hip injuries in children and adolescents may require surgical intervention. Joint-preserving procedures performed between the ages of 12 and 21 years often give good long-term results and may postpone the need for prostheses. In patients aged less than 21 years, more than 90 % of modern hip prostheses implanted in the last two decades are intact after ten years.

Outcome of 881 total hip arthroplasties in 747 patients 21 years or younger: data from the Nordic Arthroplasty Register Association (NARA) 1995-2016.

Background and purpose - The literature is scarce on the outcome of the youngest patients with total hip arthroplasties (THAs). We analyzed register data, revision risk, and related factors in patients 21 years or younger with THAs in the Nordic Arthroplasty Register Association (NARA). Patients and methods - We included all THA patients 21 years or younger reported during 1995 through 2016 to the Danish, Finnish, Norwegian, and Swedish hip arthroplasty registers and merged these into the NARA dataset. Primary outcome was any implant revision. Results - We identified 881 THAs in 747 patients. Mean age at primary surgery was 18 years (9-21). The indications for THA were pediatric hip diseases (33%), systemic inflammatory disease (23%), osteoarthritis (4%), avascular necrosis (12%), hip fracture sequelae (7%), and other diagnoses (21%). Unadjusted 10-year survival for all THAs was 86%. Comparison between indications showed no differences in survival. Uncemented implants were used most frequently. Survival for uncemented and cemented implants was the same adjusted for sex, indication, head size, and time period for primary surgery. Aseptic loosening was the main cause of revision. Interpretation - Both cemented and uncemented fixations seem to be a viable option in this age group, but with a lower implant survival than in older patient groups.

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

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

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

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

Posterior approach compared to direct lateral approach resulted in better patient-reported outcome after hemiarthroplasty for femoral neck fracture.

Background and purpose - Hemiarthroplasty (HA) is the most common treatment for displaced femoral neck fractures in many countries. In Norway, there has been a tradition of using the direct lateral surgical approach, but worldwide a posterior approach is more often used. Based on data from the Norwegian Hip Fracture Register, we compared the results of HA operated through the posterior and direct lateral approaches regarding patient-reported outcome measures (PROMs) and reoperation rate. Patients and methods - HAs due to femoral neck fracture in patients aged 60 years and older were included from the Norwegian Hip Fracture Register (2005-2014). 18,918 procedures were reported with direct lateral approach and 1,990 with posterior approach. PROM data (satisfaction, pain, quality of life (EQ-5D), and walking ability) were reported 4, 12, and 36 months postoperatively. The Cox regression model was used to calculate relative risk (RR) of reoperation. Results - There were statistically significant differences in PROM data with less pain, better satisfaction, and better quality of life after surgery using the posterior approach than using the direct lateral approach. The risk of reoperation was similar between the approaches. Interpretation - Hemiarthroplasty for hip fracture performed through a posterior approach rather than a direct lateral approach results in less pain, with better patient satisfaction and better quality of life. The risk of reoperation was similar with both approaches.

Improved outcome after hip fracture surgery in Norway.

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

Implant survival and radiographic outcome of total hip replacement in patients less than 20 years old.

Background and purpose - Total hip replacement (THR) is not recommended for children and very young teenagers because early and repetitive revisions are likely. We investigated the clinical and radiographic outcomes of THR performed in children and teenage patients. Patients and methods - We included 111 patients (132 hips) who underwent THR before 20 years of age. They were identified in the Norwegian Arthroplasty Register, together with information on the primary diagnosis, types of implants, and any revisions that required implant change. Radiographs and Harris hip score (HHS) were also evaluated. Results - The mean age at primary THR was 17 (11-19) years and the mean follow-up time was 14 (3-26) years. The 10-year survival rate after primary THR (with the endpoint being any revision) was 70%. 39 patients had at least 1 revision and 16 patients had 2 or more revisions. In the latest radiographs, osteolysis and atrophy were observed in 19% and 27% of the acetabulae and 21% and 62% of the femurs, respectively. The mean HHS at the final follow-up was 83 (15-100). Interpretation - The clinical score after THR in these young patients was acceptable, but many revisions had been performed. However, young patients with developmental dysplasia of the hip had lower implant survival. Moreover, the bone stock in these patients was poor, which could complicate future revisions.

Risk of hip fracture among older people using antihypertensive drugs: a nationwide cohort study.

BACKGROUND: Many people with a high risk of hip fracture have coexisting cardiovascular diseases. We aimed to examine associations between exposure to antihypertensive drugs and the risk of hip fracture among older people. METHODS: We conducted a cohort study of the 906,422 people born before 1945 and living in Norway in 2005. We obtained information on all prescriptions of antihypertensive drugs dispensed (the Norwegian Prescription Database) in 2004-2010 and the dates of primary hip fractures (the Norwegian Hip Fracture Registry) in 2005-2010. We compared the incidence rates of hip fracture during the time people were exposed and unexposed to antihypertensive drugs by calculating the standardized incidence ratio (SIR). RESULTS: Altogether, 39,938 people experienced a primary hip fracture (4.4 %). The risk of hip fracture was decreased among people exposed to thiazides (SIR 0.7, 95 % confidence interval (CI) 0.6-0.7), beta-blockers (SIR 0.7, 95 % CI 0.7-0.8), calcium channel blockers (SIR 0.8, 95 % CI 0.8-0.8), angiotensin II receptor blockers (SIR 0.8, 95 % CI 0.7-0.8), ACE inhibitor/thiazide combination products (SIR 0.7, 95 % CI 0.6-0.7) and angiotensin II receptor blocker/thiazide combination products (SIR 0.6, 95 % CI 0.6-0.6). Use of loop diuretics and ACE inhibitors (plain products) was associated with increased fracture risk in people born after 1924, and with decreased risk in those born before 1925. The protective associations were stronger among exposed men than among exposed women for all drugs except loop diuretics. The SIRs decreased with increasing age among exposed people, except for thiazides and angiotensin II receptor blockers. CONCLUSIONS: We found a reduced risk of hip fracture associated with overall use of most antihypertensive drugs, but an increased risk with loop diuretics and ACE inhibitors among people younger than 80 years and in new users of loop diuretics. This may have great impact at the population level, because the use of antihypertensive drugs is widespread in people at risk of hip fracture. Clinical studies are needed to further explore these associations.

Increased risk of revision for infection in rheumatoid arthritis patients with total hip replacements.

BACKGROUND AND PURPOSE: Medical treatment of rheumatoid arthritis (RA) has changed dramatically over the last 15 years, including immune modulation. We investigated the risk of revision for infection after primary total hip replacement (THR) in patients with rheumatoid arthritis over a 16-year period, and compared it with that in THR patients with osteoarthritis (OA). PATIENTS AND METHODS: We identified 13,384 THRs in RA patients and 377,287 THRs in OA patients from 1995 through 2010 in a dataset from the Nordic Arthroplasty Register Association (NARA). Kaplan-Meier survival curves, with revision for infection as the endpoint, were constructed. Cox regression analyses were performed to calculate the relative risk (RR) of revision for infection adjusted for age, sex, fixation technique, and year of primary surgery. RESULTS: RA patients had a 1.3 times (95% CI 1.0-1.6) higher risk of revision for infection. After 2001, this risk increased more for RA patients than for OA patients. During the first 3 months and from 8 years postoperatively, the risk of revision for infection was higher in RA patients with THRs fixated with antibiotic-loaded cement than in corresponding OA patients. INTERPRETATION: We found a slightly higher overall risk of revision for infection in RA patients than in OA patients, but this difference was only present after 2001. In THRs with antibiotic-loaded cement, the risk of very early and late infections leading to revision was higher in RA patients than in OA patients.

Risk of hip fracture among older people using anxiolytic and hypnotic drugs: a nationwide prospective cohort study.

PURPOSE: Anxiolytics and hypnotics are widely used and may cause injurious falls. We aimed to examine associations between exposure to anxiolytics and hypnotics and the risk of hip fracture among all older people in Norway. Further, we wanted to examine associations between exposure to hypnotics and time of fracture. METHODS: A nationwide prospective cohort study of people in Norway born before 1945 (n=906,422) was conducted. We obtained information on all prescriptions of anxiolytics and hypnotics dispensed in 2004-2010 (the Norwegian Prescription Database) and all primary hip fractures in 2005-2010 (the Norwegian Hip Fracture Registry). We compared the incidence rates of hip fracture during drug exposure and non-exposure by calculating the standardized incidence ratio (SIR). RESULTS: Altogether, 39,938 people (4.4%) experienced a primary hip fracture. The risk of hip fracture was increased for people exposed to anxiolytics (SIR 1.4, 95% confidence interval (CI) 1.4-1.5) and hypnotics (SIR 1.2, 95% CI 1.1-1.2); the excess risk was highest regarding short-acting benzodiazepine anxiolytics (SIR 1.5, 95% CI 1.4-1.6). Benzodiazepine-like hypnotics (z-hypnotics) were associated with higher excess risk of hip fracture at night (SIR 1.3, 95% CI 1.2-1.4) than during the day (SIR 1.1, 95% CI 1.1-1.2). CONCLUSIONS: Older people had an increased risk of hip fracture during anxiolytic or hypnotic drug use, including short-acting benzodiazepine anxiolytics and z-hypnotics that were previously considered less harmful; cautious prescribing is therefore needed. People using z-hypnotics were at greatest excess risk at night; this association deserves further investigation.

Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients.

BACKGROUND: Hemiarthroplasties are performed in great numbers worldwide but are seldom registered on a national basis. Our aim was to identify risk factors for reoperation after fracture-related hemiarthroplasty in Norway and Sweden. MATERIAL AND METHODS: A common dataset was created based on the Norwegian Hip Fracture Register and the Swedish Hip Arthroplasty Register. 33,205 hip fractures in individuals > 60 years of age treated with modular hemiarthroplasties were reported for the period 2005-2010. Cox regression analyses based on reoperations were performed (covariates: age group, sex, type of stem and implant head, surgical approach, and hospital volume). RESULTS: 1,164 patients (3.5%) were reoperated during a mean follow-up of 2.7 (SD 1.7) years. In patients over 85 years, an increased risk of reoperation was found for uncemented stems (HR = 2.2, 95% CI: 1.7-2.8), bipolar heads (HR = 1.4, CI: 1.2-1.8), posterior approach (HR = 1.4, CI: 1.2-1.8) and male sex (HR = 1.3, CI: 1.0-1.6). For patients aged 75-85 years, uncemented stems (HR = 1.6, 95% CI: 1.2-2.0) and men (HR = 1.3, CI: 1.1-1.6) carried an increased risk. Increased risk of reoperation due to infection was found for patients aged < 75 years (HR = 1.5, CI: 1.1-2.0) and for uncemented stems. For open surgery due to dislocation, the strongest risk factor was a posterior approach (HR = 2.2, CI: 1.8-2.6). Uncemented stems in particular (HR = 3.6, CI: 2.4-5.3) and male sex increased the risk of periprosthetic fracture surgery. INTERPRETATION: Cemented stems and a direct lateral transgluteal approach reduced the risk of reoperation after hip fractures treated with hemiarthroplasty in patients over 75 years. Men and younger patients had a higher risk of reoperation. For the age group 60-74 years, there were no such differences in risk in this material.

Increased risk of hip fracture among older people using antidepressant drugs: data from the Norwegian Prescription Database and the Norwegian Hip Fracture Registry.

BACKGROUND: hip fractures are usually caused by a combination of reduced bone mineral density and falls; using antidepressant drugs may affect both of these. OBJECTIVE: we aimed to examine associations between exposure to antidepressant drugs and the risk of hip fracture among older people, and, provided associations found, to estimate the attributable risk of hip fracture. DESIGN: we conducted a nationwide prospective cohort study of the 906,422 people in Norway born before 1945. METHODS: information on all prescriptions of antidepressants dispensed in 2004-10 and all primary hip fractures in 2005-10 was obtained from the Norwegian Prescription Database, and the Norwegian Hip Fracture Registry, respectively. The incidence rates of hip fracture during the time people were exposed and unexposed to antidepressant drugs were compared by calculating the standardised incidence ratio (SIR). RESULTS: altogether 39,938 people (4.4%) experienced a primary hip fracture. The risk of hip fracture was increased for people exposed to any antidepressant [SIR = 1.7, 95% confidence interval (CI) 1.7-1.8]; tricyclic antidepressants (SIR = 1.4, 95% CI: 1.3-1.5); selective serotonin reuptake inhibitors (SSRIs) (SIR = 1.8, 95% CI: 1.7-1.8) and other antidepressants (SIR = 1.6, 95% CI: 1.5-1.7). The risk of hip fracture attributable to exposure to antidepressant drugs was 4.7%. CONCLUSIONS: this study indicated an increased risk of hip fracture among people exposed to antidepressants, especially those with serotonergic properties such as SSRIs. This association needs to be explored further in clinical studies.

Risk factors for infection after 46,113 intramedullary nail operations in low- and middle-income countries.

BACKGROUND: The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data. METHODS: The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis. RESULTS: The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country. CONCLUSIONS: The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.

Intra- and inter-observer repeatability of radiographic measurements for previously slipped capital femoral epiphysis at skeletal maturity.

BACKGROUND: Recent studies suggest that even a mild slip of the femoral capital epiphysis may lead to later degenerative changes when undiagnosed. However, little is written on the accuracy of radiographic measurements used to diagnose a slip at skeletal maturity. PURPOSE: To assess the accuracy of radiographic measurements commonly used for assessment of previously slipped capital femoral epiphysis (SCFE) at skeletal maturity. MATERIAL AND METHODS: All children born at our hospital during 1989 (n = 4006) were invited to participate in a follow-up hip trial at age 18-19 years. Erect pelvic anteroposterior and supine frog leg radiographs were obtained in a standardized fashion. For the purpose of this study, we selected a subset of 100 radiographs. To balance the data-set, we added another 28 radiographs from skeletal mature patients diagnosed and operated for a SCFE. Two observers independently measured Southwick's head-shaft angle, Murray's tilt-index, and the femoral head-neck angle. Intra- and inter-observer variation was assessed using the mean difference, with its 95% limits of agreement. RESULTS: A high percentage of the images (40%), particularly for the measurement of the Southwick's head-shaft angle, were judged immeasurable by at least one observer. Mean head-shaft angle was 11.0° (SD = 17.0), head-neck angle was 8.0° (SD = 12.0), and Murray's tilt-index was 1.18 (SD = 0.4). For head-shaft angle, the mean difference between measurements (Observer 2) was 0.8° (SD = 2.7°, 95% limits of agreement -4.5° to 6.1°), while the corresponding figure for the Murray's tilt-index was 0.02 (SD = 0.08, 95% limits of agreement -0.18 to 0.14), and for the head-neck angle 0.9° (SD = 4.0, 95% limits of agreement of -6.9° to 8.7°). Slightly higher variance was seen for Observer 1 and between the two observers. CONCLUSION: Common radiographic measurements for the assessment of a previously slipped capital femoral epiphysis are relatively inaccurate in skeletal mature adolescents, in particular between observers (inter-observer), but also for the same observer (intra-observer). Our results underscore the importance of thorough standardization for both image and measurement technique when used in a clinical setting.

Is a positive femoroacetabular impingement test a common finding in healthy young adults?

BACKGROUND: Femoroacetabular impingement (FAI) is an incompletely understood clinical concept that implies pathomechanical changes in the hip as a cause for hip-related pain in young adults. While a positive anterior impingement test is suggestive of FAI, its association with clinical and radiographic findings remain unconfirmed in healthy young adults. QUESTIONS/PURPOSES: We determined the prevalence of a positive test in 1170 young adults and examined its possible associations with (1) self-reported hip discomfort for the past 3 months; (2) weekly physical exercise; (3) hip ROM; and (4) radiographic findings associated with femoroacetabular impingement. METHODS: We invited 2344 healthy 19-year-olds to a population-based hip study between 2008 and 2009; 1170 patients (50%) consented. The study included questionnaires on medical and functional status, a clinical hip examination including the impingement test and hip ROM, and two pelvic radiographs (AP and frog-leg views). RESULTS: Based on at least one affected hip, 35 of 480 (7.3%) men and 32 of 672 (4.8%) women had positive impingement tests. Eighteen of the 1170 patients were excluded owing to suboptimal or missing radiographs. Self-reported hip discomfort in the women and increased physical exercise in the men were strongly associated with the positive impingement tests. Decreased abduction and internal rotation in the men, decreased flexion in both genders, and radiographic cam type findings in the men also were associated with positive tests. CONCLUSION: A positive test for anterior impingement is not uncommon in healthy young adults, especially in males. We believe it always should be performed along with pelvic radiographs in young, active patients presenting with hip pain. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of level of evidence.

Perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients.

PURPOSE: Adverse events associated with the use of bone cement for fixation of prostheses is a known complication. Due to inconclusive results in studies of hip fracture patients treated with cemented and uncemented hemiprostheses, this study was initiated. METHODS: Our study is based on data reported to the Norwegian Hip Fracture Register on 11,210 cervical hip fractures treated with hemiprostheses (8,674 cemented and 2,536 uncemented). RESULTS: Significantly increased mortality within the first day of surgery was found in the cemented group (relative risk 2.9, 95 % confidence interval 1.6-5.1, p=0.001). The finding was robust giving the same results after adjusting for independent risk factors such as age, sex, cognitive impairment and comorbidity [American Society of Anesthesiologists (ASA) score]. For the first post-operative day the number needed to harm was 116 (one death for every 116 cemented prosthesis). However, in the most comorbid group (ASA worse than 3), the number needed to harm was only 33. CONCLUSIONS: We found increased mortality for the cemented hemiprosthesis the first post-operative day compared to uncemented procedures. This increased risk is closely related to patient comorbidity estimated by the patient's ASA score.

Complications after intramedullary nailing of femoral fractures in a low-income country.

BACKGROUND: Some surgeons believe that internal fixation of fractures carries too high a risk of infection in low-income countries (LICs) to merit its use there. However, there have been too few studies from LICs with sufficient follow-up to support this belief. We first wanted to determine whether complete follow-up could be achieved in an LIC, and secondly, we wanted to find the true microbial infection rate at our hospital and to examine the influence of HIV infection and lack of follow-up on outcomes. PATIENTS AND METHODS: 137 patients with 141 femoral fractures that were treated with intramedullary (IM) nailing were included. We compared outcomes in patients who returned for scheduled follow-up and patients who did not return but who could be contacted by phone or visited in their home village. RESULTS: 79 patients returned for follow-up as scheduled; 29 of the remaining patients were reached by phone or outreach visits, giving a total follow-up rate of 79%. 7 patients (5%) had a deep postoperative infection. All of them returned for scheduled follow-up. There were no infections in patients who did not return for follow-up, as compared to 8 of 83 nails in the group that did return as scheduled (p = 0.1). 2 deaths occurred in HIV-positive patients (2/23), while no HIV-negative patients (0/105) died less than 30 days after surgery (p = 0.03). INTERPRETATION: We found an acceptable infection rate. The risk of infection should not be used as an argument against IM nailing of femoral fractures in LICs. Many patients in Malawi did not return for follow-up because they had no complaints concerning the fracture. There was an increased postoperative mortality rate in HIV-positive patients.

Good results with the Ponseti method: a multicenter study of 162 clubfeet followed for 2-5 years.

BACKGROUND AND PURPOSE: In 2002-2003, several hospitals in Norway introduced the Ponseti method for treating clubfoot. The present multicenter study was conducted to evaluate the initial results of this method, and to compare them to the good results reported in the literature. PATIENTS AND METHODS: 116 children with 162 congenital idiopathic clubfeet who were born between 2004 and 2006 were treated with the Ponseti method at 8 hospitals in Norway. All children were prospectively registered at birth, and 116 feet were assessed according to Pirani before treatment was started. 63% used a standard bilateral foot abduction brace, and 32% used a unilateral above-the-knee brace. One of the authors examined all feet at a mean age of 4 years. At follow-up, all feet were assessed by Pirani's scoring system, and range of motion of the foot and ankle was measured. RESULTS: At follow-up, 77% of the feet had a Pirani score of 0.5 or better, good dorsiflexion and external rotation, and no forefoot adduction. An Achilles tenotomy had been performed in 79% of the feet. Compliance to any brace was good; only 7% were defined as non-compliant. Extensive soft tissue release had been performed in 3% of the feet. We found no statistically significant differences between the two braces, except a tendency of better Pirani score in the group using the bilateral foot abduction brace, and a tendency of better compliance in patients using the unilateral brace. Better Pirani scores were found in children who were treated at the largest hospitals. INTERPRETATION: After introducing the Ponseti method in Norway, the clinical outcome was good and in accordance with the reports from single centers. Only 5 feet needed extensive surgery during the first 4 years of life.

Total hip arthroplasty in young adults, with focus on Perthes' disease and slipped capital femoral epiphysis: follow-up of 540 subjects reported to the Norwegian Arthroplasty Register during 1987-2007.

BACKGROUND AND PURPOSE: Pediatric hip diseases account for 9% of all primary hip arthroplasties in the Norwegian Arthroplasty Register. We wanted to validate the diagnosis as reported to the register and to assess the quality of life of these patients after hip replacement. PATIENTS AND METHODS: 540 patients accepted to participate in this follow-up study (634 hips). All were less than 40 years of age and had been reported to the Norwegian Arthroplasty Register as having undergone a primary total hip arthroplasty (THA) between 1987 and 2007. The underlying diagnosis, age at diagnosis, and type of treatment given prior to the hip replacement were recorded from the original hospital notes. RESULTS: The diagnoses reported to the Norwegian Arthroplasty Register were confirmed to be correct in 91% of all cases (538/592). For the 94 hips that had been treated due to Perthes' disease or slipped capital femoral epiphysis (SCFE), the diagnosis was verified in 95% of cases (89/94). The corresponding proportion for inflammatory hip disease was 98% (137/140) and it was only 61% for primary osteoarthritis (19/31). The self reported quality of life (EQ-5D) was poorer for these young patients with THA than for persons in age-matched cohorts from Great Britain and Sweden, except for those with an underlying SCFE. INTERPRETATION: The diagnoses reported to the Norwegian Arthroplasty Register as the underlying cause of THA were correct in 91% of cases. Individuals who undergo THA before the age of 40 have a reduced quality of life, except for those requiring a hip replacement because of SCFE.