Epidemiology, Treatment, and Mortality of 3,983 Scapula Fractures from the Swedish Fracture Register.

BACKGROUND: Scapula fractures are relatively uncommon, accounting for <1% of all fractures and approximately 3-5% of shoulder girdle fractures. This study comprehensively describes the epidemiology, fracture classification, treatment, and mortality associated with scapula fractures within a large adult Swedish population. METHODS: This observational study included all patients ≥18 years old at the time of injury with a scapula fracture (ICD S42.1) registered in the Swedish Fracture Register between March 2011 and June 2020. Variables studied were age, sex, and injury mechanism, including energy level, fracture classification, associated fractures, treatment, and mortality. RESULTS: We included 3,930 patients (mean age 58 years, SD 18, 64% men) with 3,973 scapula fractures. Some 22% of the fractures were caused by high-energy trauma and 21% had at least one associated fracture. High energy-injuries were most common in glenoid neck (44%) and scapular body (35%) fractures. However, same-level falls were the most common cause of glenoid rim (62%) and intra-articular glenoid (55%) fractures. Clavicle fractures (9%) and proximal humerus fractures (5%) were the most commonly associated fractures. The most common fracture types were the glenoid rim (n=1,289, 32%) and scapular body (n=1,098, 28%) fractures. Nonoperative treatment was performed in 81% of patients. Glenoid rim and intra-articular glenoid fractures were treated operatively in over 30% of cases. The mortality rate for the whole cohort was 4% at 1 year. CONCLUSIONS: Scapula fractures are predominately sustained by men. High energetic injuries and associated fractures are present in one in five patients. Nonoperative treatment is chosen in four of five patients, but for some fracture types one in three undergo surgery.

Risk of conversion to total knee arthroplasty after surgically treated tibial plateau fractures: an observational cohort study of 439 patients.

BACKGROUND AND PURPOSE: We aimed to assess joint failure rate, i.e., subsequent conversion to TKA after surgical treatment of a tibial plateau fracture (TPF). Secondary aims were to explore the association between joint failure and fracture type, and to determine the risk of failure associated with inadequate joint surface reduction. METHODS: We included all patients ≥ 18 years of age with a surgically treated TPF, treated at Uppsala University Hospital between 2002 and 2015. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Traumatology Association (AO/OTA) classification. Postoperative radiographs were evaluated to determine the quality of joint surface inadequate reduction, defined as an articular step-off ≥ 2 mm. The study cohort was linked with the Swedish Arthroplasty Register (SAR) for information on subsequent total knee arthroplasty (TKA). RESULTS: 439 patients (57% women) with a mean age of 55 years (SD 17) were included. According to the AO/OTA classification, the fracture distribution was B1: 4.8%, B2: 10%, B3: 47%, C1: 12%, C2: 6.4%, and C3: 19%. 23 patients (5.2%) were converted to a TKA within 2 years of initial surgery, and 34 patients (7.7%) had been converted by the end of follow-up (16 years). AO/OTA type B3 and C3 had a 6.8 (95% confidence interval [CI] 1.6-29) times greater risk of joint failure compared with B1-2 and C1-C2 at 2 years' follow-up. Inadequate joint surface reduction led to an 8.4 (CI 3.6-20) times greater risk of conversion to TKA at 2 years' follow-up. CONCLUSION: Overall, 5.2% were converted to a TKA within 2 years. Fracture types AO/OTA B3 and C3 with a comminuted articular surface and inadequate joint surface reduction were strongly associated with joint failure.

Patients with more complex ankle fractures are associated with poorer patient-reported outcome: an observational study of 11,733 patients from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Patient-reported outcome measures (PROMs) following ankle fractures, including all fracture types, have not been reported. It is therefore unclear whether fracture morphology correlates with outcome. We aimed to analyze PROMs in patients with an ankle fracture in relation to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification using population-based register data from the Swedish Fracture Register (SFR). METHODS: All patients aged ≥ 18 years with an ankle fracture (AO/OTA 44A1-C3) registered in the SFR between 2012 and 2019 were retrieved from the register. Patients with completed PROM questionnaires (Short Musculoskeletal Function Assessment and EuroQol-Visual Analogue Scale) on both day 0 (pre-trauma) and 1-year post-trauma were included. The difference in PROMs between day 0 and 1 year was calculated for each patient (delta value) and mean delta values were calculated at group level, based on the AO/OTA fracture classification. RESULTS: 11,733 patients with 11,751 fractures with complete PROMs were included. According to the AO/OTA classification, 21% were A fractures, 67% were B fractures and 12% were C fractures. All groups of patients, regardless of fracture class (A1-C3), displayed an impairment in PROMs after 1 year compared with day 0. Type C fractures displayed a larger impairment in PROMs at group level than type B, which in turn had a greater impairment than type A. The same pattern was seen in groups 3, 2, and 1 for A and B fractures. CONCLUSION: We found that the AO/OTA classification is prognostic, where more complex fractures were associated with poorer PROMs.

Basicervical femoral neck fractures: an observational study derived from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR). METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality. RESULTS: The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF. CONCLUSION: Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial.

BACKGROUND: Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking. METHODS AND FINDINGS: The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely. CONCLUSIONS: In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT01246167.

The different strategies in treating displaced femoral neck fractures: mid-term surgical outcome in a register-based cohort of 1,283 patients aged 60-69 years.

BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively. PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event. RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register. CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.

Time to entry point and distal locking of intramedullary nails: a methodological phantom study comparing biplanar and uniplanar surgical imaging.

BACKGROUND: Intramedullary nailing is the method of choice for diaphyseal fractures of the femur and tibia and is also commonly used to treat trochanteric hip fractures. Perioperative imaging is essential for visualising adequate reduction, achieving an optimal entry point (EP) and performing distal locking (DL) of intramedullary nails. This methodological study aims to compare biplanar and uniplanar imaging in some steps of intramedullary nailing. METHODS: We used a biplanar preassembled imaging device (Biplanar™ 600s, Swemac Imaging) and a uniplanar imaging device (Ziehm Solo FD, Ziehm Imaging) to measure procedural and radiation times for antegrade and retrograde femoral and antegrade tibial nailing in fully soft flexible tissue encased legs with radiopaque sawbones (SKU:1515-7-11, Sawbones Europe, Malmö, Sweden). Four orthopaedic surgeons with different levels of experience performed all procedures in all three phantoms with both image techniques in random order, producing in total 12 EPs and nailings with DL with each imaging device. Time to EP, radiation times, time to DL for both devices and the number of swings of the uniplanar device for the two procedures were measured. Comparisons between the biplanar and uniplanar systems with a paired-samples t-test were conducted. RESULTS: Using the biplanar device, time to optimal EP was shorter for retrograde femoral (26 s (SD15) vs 35 s (SD13), p = 0.01) and for antegrade tibial nailing (23 s (SD13) vs 49 s (SD24), p = 0.001). No statistically significant differences in time to EP, radiation time or time to DL were found for antegrade femoral nailing. A median of two swings of the uniplanar device was needed to obtain optimal EP for all procedures. CONCLUSIONS: Biplanar imaging slightly but statistically significantly reduced time to EP for retrograde femoral and antegrade tibial nailing in this methodological study comparing biplanar and uniplanar imaging techniques. Biplanar imaging can reduce time and radiation exposure when defining the EP around the knee in intramedullary nailing procedures, but the clinical relevance of these time savings remain to be defined. For antegrade femoral nailing we found no clear benefit with biplanar imaging in the investigated steps of nailing.

Epidemiology of proximal and diaphyseal humeral fractures in children: an observational study from the Swedish Fracture Register.

BACKGROUND: Most fractures in children are fractures of the upper extremity. Proximal and diaphyseal humeral fractures account for a minority of these fractures. To our knowledge, few previous reports address these fractures. This study aimed to describe the epidemiology and current treatment of proximal and diaphyseal humeral fractures by using the Swedish Fracture Register (SFR). METHODS: In this nationwide observational study from the SFR we analysed data on patient characteristics, injury mechanism, fracture classification and treatment. We included patients aged < 16 years at time of injury with proximal or diaphyseal humeral fracture registered in 2015-2019. RESULTS: 1996 (1696 proximal and 300 diaphyseal) fractures were registered. Proximal fractures were more frequent in girls whereas diaphyseal fractures were more frequent in boys. The median age at fracture was 10 years in both fracture types but patient's age was more widespread in diaphyseal fracture (IQR 5-13 compared to IQR 7-12 in proximal). In both sexes, the most registered injury mechanism was fall. Horse-riding was a common mechanism of injury in girls, whereas ice-skating and skiing were common mechanisms in boys. Most proximal fractures were metaphyseal fractures. Most diaphyseal fractures were simple transverse or oblique/spiral fractures. The majority of fractures were treated non-surgically (92% of proximal and 80% of diaphyseal fractures). The treatment method was not associated with the patient's sex. Surgery was more often performed in adolescents. The most common surgical methods were K-wire and cerclage fixation in proximal fracture and intramedullary nailing in diaphyseal fracture. CONCLUSION: Following falls, we found sex-specific sport activities to cause most proximal and diaphyseal paediatric fractures. Further studies on prophylactic efforts in these activities are needed to investigate whether these fractures are preventable. The majority of the fractures were treated non-surgically, although surgical treatment increased with increasing age in both sexes. TRIAL REGISTRATION: Not applicable. The present study is a register-based cohort study. No health care intervention had been undertaken.

Clinical outcomes of patients with Garden I and II femoral neck fractures as verified on MRI: a retrospective case series.

BACKGROUND: Between 2 to 10% of non-displaced femoral neck fractures (nFNF) cannot be diagnosed on plain radiographs and require further imaging investigation to be detected or verified. These fractures are referred to as occult hip fractures. This study aimed to report treatment failures, reoperations and mortality in a consecutive series of occult femoral neck fractures (FNF) treated with internal fixation (IF). METHODS: A retrospective multicenter study was performed based on a consecutive series of patients aged ≥ 60 years with an occult magnetic resonance imaging (MRI) verified Garden I and II FNF sustained after a trauma and treated with primary IF. We included 93 patients with a minimum 2-year follow-up. Radiographic assessment encompassed pre- and postoperative tilt, implant inclination, MRI and treatment failure. Data on reoperation and mortality were collected. Treatment failure was defined as fixation failure, nonunion, avascular necrosis or posttraumatic osteoarthritis. RESULTS: The study comprised of 93 patients (72% women, 67/93) with a mean age of 82 (range, 60-97) years. Overall, 6 (6%) patients had major reoperations. 2 (2%) had minor reoperations. One-month mortality was 7%, 1-year mortality was 20% and 2-year mortality was 31%. CONCLUSION: This multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. These fractures seem to have a lower complication rate compared to nFNF identified on plain radiographs. LEVEL OF EVIDENCE: Prognostic Level V. See Instructions to Authors for a complete description of levels of evidence.

The Swedish Fracture Register - ten years of experience and 600,000 fractures collected in a National Quality Register.

BACKGROUND: Before the creation of the Swedish Fracture Register (SFR), there was no national quality register that prospectively collects data regarding all types of fractures regardless of treatment in an emergency setting. Observational data on fractures registered in a sustainable way may provide invaluable tools for quality improvements in health care and research. DESCRIPTION: Ten years after its implementation, the Swedish Fracture Register has 100% coverage among orthopaedic and trauma departments in Sweden. The completeness of registrations reached in 2020 69-96% for hip fractures at the different departments, with the majority reporting a completeness above 85%. The Swedish Fracture Register is a fully web-based national quality register created and run by orthopaedic professionals, with financial support from public healthcare providers and the government. All users have full access to both the registration platform and all aggregated statistics in real time. The web-based platform was created for use in health quality registers and it has easily gained acceptance among users. The register has gradually developed by the addition of more fracture types and skeletal parts. Research activity is high and 31 scientific publications have been published since 2016. The strategy from the start was to publish validation data and basic epidemiological data. However, over the past few years, publications on outcomes, such as re-operations and mortality, have been published and four register-based, randomised, controlled trials are ongoing. CONCLUSION: It is possible to create a fracture register, to gain professional acceptance and to collect fracture data in a sustainable way on a national level if the platform is easy to use. Such a platform can also be used as a randomisation platform for prospective studies.

Lower mortality in distal femoral fractures in the presence of a knee arthroplasty: an observational study on 2,725 fractures from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Distal femoral fractures (DFF) in older patients have mortality rates comparable to fractures of the proximal femur. An ageing population combined with an increasing number of patients undergoing total knee arthroplasty (TKA) will make periprosthetic distal femoral fractures (pDFF) more common. We investigated whether a pre-existing TKA influences mortality rates. PATIENTS AND METHODS: All patients ≥ 60 years registered in the Swedish Fracture Register with a DFF sustained between March 20, 2011 and December 31, 2020 were included. The study cohort comprised 2,725 patients, of which 650 had a pDFF. Unadjusted 90-day and 1-year mortality was estimated via Kaplan-Meier survival curves. A Cox regression model adjusted for age, sex, and treatment modality was used to investigate the association between DFF or pDFF and mortality. RESULTS: Mean age was 80 years and 82% were females. The most common injury mechanism was a simple fall (75%). The pDFF and DFF group were similar with regards to age, sex, and trauma mechanism. Unadjusted 90-day and 1-year mortality was 11% (95% CI 10-12) and 21% (CI 19-23), respectively. Kaplan-Meier survival analysis demonstrated a slightly lower mortality for pDFFs, especially in patients ≤ 70 years. The Cox regression model showed a lower hazard ratio (HR) for mortality in the pDFF group (HR 0.82, CI 0.71-0.94). INTERPRETATION: In a large cohort of patients ≥ 60 years with a distal femoral fracture, mortality rates at 90 days and 1 year post-injury were 11% and 21%, respectively. Periprosthetic fractures were associated with a lower mortality.

Increased mortality after intramedullary nailing of trochanteric fractures: a comparison of sliding hip screws with nails in 19,935 patients.

Background and purpose - Intramedullary nails (IMN) have become increasingly common as treatment for trochanteric hip fractures (THF) although they are costlier, and without proven superiority compared with sliding hip screws (SHS). We investigated whether the 2 methods differ in terms of short-term mortality when used in fractures where both methods are suitable. Patients and methods - We extracted data from the Swedish Fracture Register (SFR) on 19,935 patients ≥ 60 years with trochanteric fractures AO type 31-A1 or -A2 who had been treated with either SHS or IMN. We assessed absolute mortality rates and the relative risks (RR) of death after 7, 30, 90, and 365 days using generalized linear models, adjusting for age, sex, and fracture type. We performed a sensitivity analysis on a subgroup of 3,673 patients with information on comorbidity to address this potential confounder. Results - 69% of the patients were women and mean age was 84 years (60-107). IMN was used in 35% of A1 and in 71% of A2 fractures. The use of IMN was associated with a slightly increased adjusted risk of death within 30 days compared with SHS (RR = 1.1, 95% CI 1.0-1.2) with no difference at any other time point. Interpretation - The slightly increased risk of death up to 30 days postoperatively does not support the use of IMN instead of SHS in stable THF.

Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Stress fractures of the femoral neck (sFNFs) are uncommon injuries. Studies on sFNFs are rare. We describe the demographics, classification, treatment, reoperation rates, and mortality in a cohort of sFNF patients from the Swedish Fracture Register (SFR). PATIENTS AND METHODS: We included 146 patients ≥ 18 years of age with an sFNF registered in the SFR between 2011 and 2020. The cohort was linked with the Swedish Arthroplasty Register and reviewed using medical records and radiographs. We assessed the presence of disorders of bone remodeling, duration of symptoms, fracture classification, treatment, reoperations, and mortality. RESULTS: The mean age was 58 years (21-96), 75% were women and the median duration of symptoms was 23 days (1-266). 40% of patients had disorders of bone remodeling. 54% were undisplaced (uFNF), 30% displaced (dFNF), and 16% basicervical (bFNF). 14% of patients < 60 years were treated nonoperatively, by internal fixation (IF) in 77% and by arthroplasty in 10%. Patients ≥ 60 years were treated nonoperatively in 10%, IF in 40%, and arthroplasty in 49%. Nonoperative treatment was reserved for uFNFs or bFNFs, resulting in 35% receiving late surgery. The overall secondary or late surgery rate was 19%. Mortality was 2% at 90 days and increased to 3% at 1 year. INTERPRETATION: sFNF has a biphasic age distribution. One-third of patients presented with a displaced FNF and those managed nonoperatively for an undisplaced sFNF were at risk of late surgery. The mortality rates for patients with these injuries was low.

Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial.

BACKGROUND AND PURPOSE: Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF. STUDY DESIGN: The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.

Epidemiology, classification, treatment and mortality of Talus fractures: An observational study of 1794 talus fractures from the Swedish Fracture Register.

BACKGROUND: Epidemiological data on talus fractures from large nationwide and multicenter studies are rare. This study aims to describe the epidemiology, fracture classification and treatment regimens of talus fractures in a large adult Swedish population. METHODS: This observational study is based on data from the Swedish Fracture Register (SFR) including talar fractures in patients ≥18 with a sustained fracture between 2012 and 2021. Epidemiological data on sex, age, injury date, injury mechanism and type (high or low energy trauma), fracture classification (side, type), initial treatment and mortality were analysed. RESULTS: We included 1794 talus fractures (1757 patients, 60 % men). Mean age was 40.3 years (range 18-96), and a biphasic age distribution was seen in women. High-energy trauma caused 33 % of all talus fractures. Of all talus fractures, 817 (45.5 %) were classified as AO/OTA type A fractures (avulsion), 370 (20.6 %) as type B (neck) and 435 (24.2 %) as type C (body). The remaining 172 (9.6 %) talus fractures were not classified/unclassifiable. Men were in the majority in all fracture groups except A1. For type A1-3, B1 and C1-2 fractures, most patients were treated non-operatively; in B2-3 and C3 fractures most patients received operative management. Fracture fixation with screws was the dominating surgical treatment. The overall 30-day mortality was 0.2 %. CONCLUSION: Talus fractures are most commonly encountered in young and middle-aged men. In contrast to men, a biphasic age distribution was observed in women. Approximately half of the talus fractures are avulsions. Operative treatment, mostly screw fixation, is performed in more complex fracture configurations (B2, B3 and C3 fractures). LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

Does the Covid-19 pandemic affect ankle fracture incidence? Moderate decrease in Sweden.

Background and purpose - While many other countries implemented strict regulations and restrictions for their citizens during the 1st wave of the Covid-19 pandemic, Sweden maintained a more restrained approach. The Swedish Public Health Agency emphasized individual responsibility and pushed for behavioral changes. With strict lockdown a 77% decrease in ankle fracture incidence has been reported. We investigated whether there was a change in the incidence of ankle fractures seen at 7 selected hospitals during the Covid-19 pandemic 2020.Patients and methods - Data on all ankle fractures treated at 7 selected departments during March 15 through June 15, 2020, and for the same period in the preceding 3 years (2017-2019), was retrieved from the Swedish Fracture Register. The number of fractures during the whole period and subsequent 30-day periods were compared between 2020 and 2017-2019, including subgroup analyses of age and sex.Results - The monthly rate of ankle fractures was reduced by 14% in 2020 (139 fractures) compared with 2017-2019 (161 fractures). Women had a 16% decrease and patients aged > 70 years had a 29% decrease. During the 1st 30-day period, a 26% decrease in fractures was seen.Interpretation - During the 1st wave of the Covid-19 pandemic, a moderate decline in the number of ankle fractures was seen. Women and patients aged > 70 years displayed the greatest reduction. The greatest reduction in incidence of fractures was seen during the 1st 30-day period. This indicates greater adherence to government recommendations regarding social distancing in these subgroups and during the 1st month of the pandemic. Changes in ankle fracture incidence may be a measure of lockdown extent.

How deadly is a fracture distal to the hip in the elderly? An observational cohort study of 11,799 femoral fractures in the Swedish Fracture Register.

Background and purpose - Unlike hip fractures, diaphyseal and distal femoral fractures in elderly patients have not been widely studied. We investigated the demographics, comorbidities and mortality of patients with femoral fractures at any anatomical level with a focus on early mortality.Patients and methods - We analyzed 11,799 patients ≥ 65 years with a femoral fracture registered in the Swedish Fracture Register from 2011 to 2014. The cohort was matched with the National Patient Register to obtain data on comorbidities classified according to the Charlson Comorbidity Index (CCI). Generalized linear models were fitted to estimate the adjusted relative risk of mortality.Results - Mean age of the cohort was 83 years and 69% were women. Patients with distal femoral fractures had the lowest degree of comorbidity, with 9% having a CCI of ≥ 3 compared with 14% among those with proximal and 16% among those with diaphyseal fractures. Unadjusted 90-day mortalities were 13% (95% CI 9.4-16) after fractures in the distal, 13% (CI 10-16) in the diaphyseal, and 15% (CI 14-15) in the proximal segment. The adjusted relative risk for 90-day mortality was 1.1 (CI 0.86-1.4) for patients with distal and 0.97 (CI 0.76-1.2) for patients with diaphyseal femoral fractures when compared with patients with hip fractures.Interpretation - Elderly patients with femoral fractures distal to the hip may have similar adjusted early mortality risks to those with hip fractures. There is a need for larger, preferably prospective, studies investigating the effect of rapid pathways and geriatric co-management for patients with diaphyseal and distal femoral fractures.

Study protocol: HipSTHeR - a register-based randomised controlled trial - hip screws or (total) hip replacement for undisplaced femoral neck fractures in older patients.

BACKGROUND: Femoral neck fractures (FNFs), which are common in the older population, are associated with high mortality and morbidity. Some 20% of FNFs are undisplaced (uFNFs). The routine surgical procedure for uFNFs is internal fixation (IF) with 2-3 screws/pins with a reported reoperation rate in older patients (age ≥ 75 years) of up to 21%. The reoperation rate for hemiarthroplasties for displaced fractures is lower than for undisplaced fractures operated with IF. This study will aim to determine whether the outcome for older patients with an uFNF can be improved by replacing the hip instead of preserving it. METHODS: A national multicentre, register-based, randomised controlled trial (rRCT) will be conducted. For this trial, 1440 patients, ≥75 years with an acute uFNF, will be allocated. Eligible patients will be identified by the Swedish Fracture Register (SFR) platform, which will notify the admitting orthopaedic surgeon of eligibility. After informed consent has been given and documented, patients will be randomised to either IF (control group) or arthroplasty (intervention group) within the SFR platform. Injury mechanism, fracture classification, date of injury, and type of treatment are registered in the SFR. Type and brand of arthroplasty, surgical approach, and fixation are obtained from the Swedish Hip Arthroplasty Register (SHAR). The study cohort from the SFR will be cross-checked with the National Patient Register and the SHAR for outcome variables at 2, 5, and 10 years. The primary outcome will be a composite variable comprising reoperation rate and mortality at 2 years postoperatively. Secondary endpoints will include reoperation rate and mortality as stand-alone variables. In addition, secondary endpoints will be patient-reported outcomes as measured by the Short Musculoskeletal Functional Assessment questionnaire at 1 year postoperatively as routinely collected within the SFR. Further secondary endpoints will include the occurrence of adverse events such as pneumonia, stroke or myocardial infarction and evaluation of the external validity of the study. DISCUSSION: This large, multicentre, register-based randomised controlled trial could potentially shift the treatment of uFNFs in older patients towards primary hip arthroplasty in order to improve the outcome. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov (NCT03966716); May 29, 2019.

Epidemiology of pediatric femur fractures in children: the Swedish Fracture Register.

BACKGROUND: Although femur fractures in children are rare, they are the most common fractures in need of hospitalization. We sought to describe the epidemiology and treatment of pediatric femur fractures recorded in the Swedish Fracture Register (SFR). We also studied the relationship between femur fractures, age, sex, fracture pattern, injury mechanism, seasonal variation and treatment. METHODS: This nationwide observational register study was based on the pediatric part of the SFR. We included all patients < 16 years of age who were registered in the SFR from 2015 to 2018. RESULTS: Of the 709 femur fractures, 454 (64%) occurred in boys. Sixty-two of these fractures were proximal (9%), 453 shaft (64%) and 194 distal (27%). A bimodal age distribution peak was observed in boys aged 2-3 and 16-19 years. In contrast, the age distribution among girls was evenly distributed. Younger children were mainly injured by a fall, whereas older children sustained their fracture because of traffic accidents. Non-surgical treatment prevailed among younger children; however, prevalence of surgical treatment increased with age. CONCLUSIONS: We found a lower ratio between boys and girls (1.8:1) compared to earlier studies. The bimodal age distribution was seen only in boys. Falls were the most common injury in younger children, whereas traffic-related accidents were the most common in adolescents. With age, there was a corresponding increase in surgical treatment.

Study protocol: The DUALITY trial-a register-based, randomized controlled trial to investigate dual mobility cups in hip fracture patients.

Background and purpose - Physically and mentally fit patients with a displaced femoral neck fracture (FNF) are mostly treated with total hip arthroplasty (THA). Dislocation is a severe and frequent complication in this group, and dual mobility cups (DMC) were developed to reduce the risk of dislocation after THA. The DUALITY trial investigates whether the use of DMC in FNF patients treated with a THA reduces the risk of dislocation.Patients and methods - The trial is a national, multicenter, register-based, randomized controlled trial (rRCT). Patients ≥ 65 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) who are suitable for a THA according to local guidelines are assessed for eligibility using the web-based registration platform of the Swedish Fracture Register (SFR). 1,600 patients will be randomized 1:1 to either insertion of a DMC (intervention group) or a standard cup (control group). The study is pragmatic in that the choice of implant brands, surgical approach, and peri- and postoperative protocols follow the local routines of each participating unit. All outcome variables will be retrieved after linkage of the study cohort obtained from the SFR with the Swedish Hip Arthroplasty Register and the National Patient Register.Outcomes - The primary outcome is the occurrence of any dislocation of the index joint treated with closed or open reduction within 1 year after surgery, expressed as a relative risk when comparing groups, and a risk reduction of at least 45% is considered clinically relevant. Secondary outcomes are the relative risk of any reoperation of the index joint, periprosthetic joint infection, and mortality within 90 days and 1 year. Patient-reported outcomes and health economics are evaluated.Start of trial and estimated duration - The DUALITY trial started recruiting patients in January 2020 and will continue for approximately 5 years.Trial registration - The trial is registered at clinicaltrials.gov (NCT03909815; December 12, 2019).