Diagnosis of Open Tibial Fracture Showed High Positive Predictive Value in the Swedish National Patient Register.

INTRODUCTION: The Swedish National Patient Register was validated only for a few diagnoses in the field of trauma. In this study, we calculated the positive predictive values (PPV) of the diagnosis of open tibial fracture and corresponding E-codes (cause of injury). PATIENTS AND METHODS: Out of 2845 cases from a 10-year period (2007-2016), a random sample of 300 cases was selected for review of medical records. The accuracy of the diagnosis and cause of injury was calculated and presented as PPV. We divided the study population into two subgroups (moderate and severe injury) that were analyzed separately. Severe injury was defined as when a patient had an amputation and/or reconstructive surgical procedures, indicated by corresponding ICD-codes. RESULTS: The PPV of the diagnosis of open tibial fracture was 87% (95% CI: 86-88%) overall, 86% (95% CI: 79-91%) for moderate injuries and 96% (95% CI: 91-98%) for severe injuries. The PPV for E-codes was 74% (95% CI: 65-81%). The majority of injuries were caused by falls (47%) or transport accidents (38%). Most of these injuries were caused by high-energy trauma (60%). CONCLUSION: The PPV of the diagnosis of open tibial fracture in the Swedish National Patient Register is high (87%). The PPV of E-codes was lower (79%). The results imply that the register is well suited for healthcare evaluation and research purposes regarding trauma diagnoses. Most open tibial fractures are high-energy injuries.

Sequence of 305,996 total hip and knee arthroplasties in patients undergoing operations on more than 1 joint.

Background and purpose - Patient-specific data on multiple total arthroplasties (TA) of the lower limbs due to osteoarthritis (OA) are limited. We investigated the sequence of surgical procedures and risk factors for additional surgery in such patients. Patients and methods - 305,996 patients operated with a TA of the hip and/or knee due to OA were extracted from the Swedish National Hip (SHAR) and the Swedish Knee Arthroplasty Register (SKAR). 177,834 total hip arthroplasty (THA, 56% women, mean age 69 years) and 128,162 total knee arthroplasty (TKA, 60% women, mean age 69 years) procedures constituted the index operations. The mean, median, and maximum follow-up was 8, 6, and 23 years. Multivariable Cox regression analysis was used and Kaplan-Meier survival curves were constructed. Results - Right-sided primary TA (34%) was most frequent. Subsequent surgery was most frequent after primary left-sided TKA (33%). The time interval to a second TA procedure was 3.1 (SD 3.2) years after TKA and 4.0 (SD 3.9) years after THA. After the index TA the probability of no subsequent surgery amounted to 64% (SD 0.3) for THA and 58% (SD 0.4) for TKA over 20 years. Lower age, female sex, left side, and TKA at index operation were associated with a higher probability for subsequent TA. Interpretation - Delineation of factors that influence risk and the size of the risk for subsequent TA in 1 of the 3 major remaining joints is of value for clinicians and healthcare providers in the decision-making process for future resource allocation.

Increased early mortality and morbidity after total hip arthroplasty in patients with socioeconomic disadvantage: a report from the Swedish Hip Arthroplasty Register.

Background and purpose - Socioeconomic status is associated with the outcome of major surgery. We investigated the association of socioeconomic status with the risk of early mortality and readmissions after primary total hip arthroplasty (THA). Patients and methods - We obtained information on income, education, immigration, and cohabiting status as well as comorbidities of 166,076 patients who underwent primary THA due to primary osteoarthritis (OA) from the Swedish Hip Arthroplasty Register, the Swedish National Inpatient Register and Statistics Sweden. Multivariable Cox regression models were fitted to estimate the adjusted risk of mortality or readmissions within 90 days after index surgery. Results - Compared with patients on a low income, the adjusted risk of 30-day mortality was considerably lower in patients on a high income (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.3-0.7) and in those on a medium income (HR 0.7, CI 0.6-0.9). Similar risk reductions were found for the endpoint 90-day mortality. Patients with a high income had a lower adjusted risk of readmission for cardiovascular reasons than those with a low income (HR 0.7, CI 0.6-0.9), as had those with a higher level of education (adjusted HR 0.7, CI 0.6-0.9). Patients with higher socioeconomic status had a lower degree of comorbidities than socioeconomically disadvantaged patients. However, adjusting for socioeconomic confounders in multivariable models only marginally influenced the predictive ability of the models, as expressed by their area under the curve. Interpretation - Income and level of education are strongly associated with early mortality and readmissions after primary THA, and both parameters are closely connected to health status. Since adjustment for socioeconomic confounders only marginally improved the predictive ability of multivariable regression models our findings indicate that comorbidities may under certain circumstances serve as an acceptable proxy measure of socioeconomic background.

Mortality, risk factors and causes of death in Swedish patients with open tibial fractures - a nationwide study of 3, 777 patients.

BACKGROUND: Open tibial fractures are serious, complicated injuries. Previous studies suggested an increased risk of death, however, this has not been studied in large population-based settings. We aimed to analyze mortality including causes of death in all patients with open tibial fractures in Sweden. Moreover, we wanted to compare mortality rates with the Swedish population and determine whether treatment-related or demographic variables were independently associated with death. METHOD: We searched the Swedish National Hospital Discharge Register for all patients with open tibial fracture between 1998 and 2010. We collected the following variables: age, gender, length of stay, mechanism of injury and treatment rendered. We then cross-referenced the Swedish Cause of Death Register to determine the cause of death, if applicable. We compared mortality in the study population with population-based mortality data from Statistics Sweden and determined whether variables were independently associated with death using regression analysis. RESULTS: Of the 3777 open tibial fractures, 425 (11.3%) patients died. The most common causes of death for elderly patients were cardiovascular and respiratory disease. Patients aged 15-39 years succumbed to external causes (accidents, suicides or poisoning). Increasing age (OR 25.7 (95% CI 11.8-64.8) p < 0.001), length of hospital stay (HR 1.01, (95% CI 1.01-1.02,) p < 0.001), limb amputation (OR 4.8 (95% CI 1.86-11.1) p < 0.001) and cause of the accident were independently associated with an increased mortality. CONCLUSION: Patients with open tibial fractures have an increased risk of death compared with the general population in all age- and gender-groups. External causes of death are over-represented and indicate a subgroup with a risky behaviour among younger males. Elderly patients have an increased risk of dying comparable to hip fracture patients. They are at risk for cardiovascular and respiratory failure and should be treated with urgency, emphasizing the need for specialized geriatric trauma units.

Good clinical and radiographic outcome of cementless metal metaphyseal sleeves in total knee arthroplasty.

Background and purpose - The number of revision total knee arthroplasties (TKA) is continuously increasing, leading to a growing need for reliable management of metaphyseal bone loss. We evaluated patients operated with a TKA using metal metaphyseal sleeves for bone defects with a minimum 5-year follow-up. Patients and methods - 37 patients had been operated on. 3 patients died and 3 patients were lost during follow-up. Of the 31 remainders (20 women), 9 had been operated on with a primary TKA and 22 with a revision TKA at the index surgery. The mean age at surgery was 69 (54-89) years and the mean follow-up time was 7.4 (5-12) years. Bone defects were classified according to the Anderson Orthopaedic Research Institute classification (tibia: type I n = 9, type II n = 5 and type III n = 17; femur: type I n = 12, type II n = 3 and type III n = 16). Results - At final follow-up one-third experienced an improvement concerning walking aids and walking distance. Except for 1 patient, all had full extension and a mean knee flexion of 110 (90-140) degrees. VAS pain at rest was 13 (SD 25) and on movement 30 (SD 31). 7 patients were reoperated due to: infection (n = 4), periprosthetic fracture (n = 1), skin necrosis (n = 1), and wound rupture (n = 1). The cumulative 5-year survival rate for reoperation was 77% (CI 63-92) and for revision 97% (CI 91-100). At the time of final follow-up, the sleeves showed good osseointegration with no signs of progressive radiolucency or migration. Interpretation - Titanium sleeves are a promising option in managing difficult cases with metaphyseal bone defects in TKA, providing a stable construct with good medium-term radiographic outcome.

Comparison of metal ion concentrations and implant survival after total hip arthroplasty with metal-on-metal versus metal-on-polyethylene articulations.

Background and purpose - Large metal-on-metal (MoM) articulations are associated with metal wear and corrosion, leading to increased metal ion concentrations and unacceptable revision rates. There are few comparative studies of 28-mm MoM articulations with conventional metal-on-polyethylene (MoP) couplings. We present a long-term follow-up of a randomized controlled trial comparing MoM versus MoP 28-mm articulations, focused on metal ions and implant survival. Patients and methods - 85 patients with a mean age of 65 years at surgery were randomized to a MoM (Metasul) or a MoP (Protasul) bearing. After 16 years, 38 patients had died and 4 had undergone revision surgery. 13 patients were unavailable for clinical follow-up, leaving 30 patients (n = 14 MoM and n = 16 MoP) for analysis of metal ion concentrations and clinical outcome. Results - 15-year implant survival was similar in both groups (MoM 96% [95% CI 88-100] versus MoP 97% [95% CI 91-100]). The mean serum cobalt concentration was 4-fold higher in the MoM (1.5 µg/L) compared with the MoP cohort (0.4 µg/L, p < 0.001) and the mean chromium concentration was double in the MoM (2.2 µg/L) compared with the MoP cohort (1.0 µg/L, p = 0.05). Mean creatinine levels were similar in both groups (MoM 93 µmol/L versus MoP 92 µmol/L). Harris hip scores differed only marginally between the MoM and MoP cohorts. Interpretation - This is the longest follow-up of a randomized trial on 28-mm MoM articulations, and although implant survival in the 2 groups was similar, metal ion concentrations remained elevated in the MoM cohort even in the long term.

Total Hip Arthroplasty in 6690 Patients with Inflammatory Arthritis: Effect of Medical Comorbidities and Age on Early Mortality.

OBJECTIVE: We analyzed early mortality after total hip arthroplasty (THA) in patients with inflammatory arthritis (IA), adjusting for medical comorbidities and socioeconomic background. METHODS: Data on 6690 patients with IA who underwent THA during 1992-2012 were extracted from the Swedish Hip Arthroplasty Register. Data on comorbidity, measured using the Charlson Comorbidity Index (CCI), and socioeconomic data were gathered from the Swedish National Inpatient Register and Statistics Sweden. The CCI was divided into low (0), moderate (1-2), and high (> 2). Cox proportional hazards models were fitted to calculate adjusted HR of early mortality, with 95% CI. RESULTS: Twenty-five patients (0.4%) died within 0-90 days, giving a 90-day unadjusted survival rate of 99.6% (CI 99.5-99.8). Comorbidity was associated with an increased risk of death within 90 days postoperatively [high vs low CCI: adjusted HR 9.0 (CI 1.6-49.9)]. There was a trend toward lower risk of death during the period 1999-2005, although patients operated on during this period had more comorbidities than those operated on from 1992 to 1998. A large proportion of patients was re-admitted to hospital within 90 days after the index procedure (30.2%), but rarely for cardiovascular reasons. CONCLUSION: Medical comorbidity and an age above 75 years are associated with a substantial increase in the risk of early death after THA in patients with IA. Awareness of potential risk factors may alert clinicians and thus improve perioperative care.

Lower extremity soft tissue reconstruction and amputation rates in patients with open tibial fractures in Sweden during 1998-2010.

BACKGROUND: The rates of soft tissue reconstruction and amputation after open tibial fractures have not been studied on a national perspective. We aimed to determine the frequency of soft tissue coverage after open tibial fracture as well as primary and secondary amputation rates. METHODS: Data on all patients (> = 15 years) admitted to hospital with open tibial fractures were extracted from the Swedish National Patient Register (1998-2010). All surgical procedures, re-admissions, and mechanisms of injury were analysed accordingly. The risk of amputation was calculated using logistic regression (adjusted for age, sex, mechanism of injury, reconstructive surgery and fixation method). The mean follow-up time was 6 (SD 3.8) years. RESULTS: Of 3,777 patients, 342 patients underwent soft tissue reconstructive surgery. In total, there were 125 amputations. Among patients with no reconstructive surgery, 2% (n = 68 patients) underwent amputation. In an adjusted analysis, patients older than 70 years (OR = 2.7, 95%, CI = 1.1-6) and those who underwent reconstructive surgery (OR = 3.1, 95% CI = 1.6-5.8) showed higher risk for amputation. Fixations other than intramedullary nailing (plate, external fixation, closed reduction and combination) as the only method were associated with a significant higher risk for amputation (OR 5.1-14.4). Reconstruction within 72 hours (3 days) showed better results than reconstruction between 4-90 days (p = 0.04). CONCLUSIONS: The rate of amputations after open tibial fractures is low (3.6%). There is a higher risk for amputations with age above 70 (in contrast: male sex and tissue reconstruction are rather indicators for more severe soft tissue injuries). Only a small proportion of open tibial fractures need soft tissue reconstructive surgery. Reconstruction with free or pedicled flap should be performed within 72 hours whenever possible.

2- to 9-year outcome of stemmed total knee arthroplasty. Similar failure rates in patients when used primary or as a revision.

BACKGROUND AND PURPOSE: There is an increase in demand for primary and revision total knee joint procedures. We studied implant survival and functional outcome of patients operated with a constrained condylar knee (CCK) or a rotating hinge implant (RH) as a primary or a revision total knee arthoplasty (TKA). PATIENTS AND METHODS: We evaluated clinically and radiographically 65 surgical procedures with a mean follow-up time of 5 (2-9) years (40 CCK and 25 RH). There were 24 primary TKAs-due to instability-and 41 revision TKAs, mostly due to aseptic loosening. Mean age at the index operation was 68 (31-88) years. RESULTS: Overall, there were 12 failures, including 8 reoperations due to deep infection. The overall 5-year survival rate with reoperation as the endpoint was 82% (95% CI: 72-99). Radiolucent lines on either the femoral or the tibial side were seen in 36 cases. When comparing the cases that were operated as a primary TKA or as a revision TKA, function, health-related quality of life, and survival were similar. However, after primary TKA the patients generally had less pain and a higher proportion of patients were very satisfied or satisfied. INTERPRETATION: Although a high rate of severe complications was observed, most patients improved in function after surgery regardless of whether it was a primary or a revision TKA. We found narrow radiolucent lines-mainly on the tibial side-in nearly half of the cases, but none of the implants were loose radiographically. Overall patient satisfaction and health-related quality of life were high, and a minority had problems with persistent pain.

Skeletal metastases in 301 breast cancer patients: patient survival and complications after surgery.

The aim was to identify prognostic variables associated with survival in 301 breast cancer patients after surgical treatment of skeletal metastases. The study period was 1986-2012. The median age at surgery was 61 (interquartile-range [IQR] 52-70) years. The cumulative 1-, 2-, and 5-year survival after surgery was 45% (95% CI 39-51), 27% (22-32), and 8% (5-12), respectively. The median follow-up time was 1 (IQR 0.2-2) year. Age over 60 years (Hazard ratio [HR] 1.9) and hemoglobin levels <110 g/L (HR 2) increased the risk of death after surgery. Patients with impending fractures (HR 0.4) had a lower death rate. The overall neurological function in patients with spinal metastases improved after surgery (p < 0.001). The complication rate was 25%, including 14% re-operations. Survival data and analysis of complications of this large cohort of surgically treated breast cancer patients help to set appropriate expectations for the patients, families, and medical staff.

Clinical imaging assessments of knee osteoarthritis in the elderly: a mini-review.

Knee osteoarthritis (OA) in the elderly is one of the most common degenerative age-related joint diseases leading to typical degradation of articular cartilage with severe pain and limitation of joint motion. Its increasing prevalence due to the demographic development of the society has major implications for individual and public healthcare with the increasing necessity for clinical imaging assessment in a high number of individuals. Although conventional X-ray radiographs are widely considered as gold standard for the assessment of knee OA, in clinical and scientific settings they increasingly bare significant limitations in situations when high resolution and detailed assessment of cartilage is demanded. New imaging modalities are broadening the possibilities in knee OA clinical practice and are offering new insights to help for a better understanding of the disease. X-ray analysis in OA of the knee is associated with many technical limitations and increasingly is replaced by high-quality assessment using magnetic resonance imaging or ultrasonography both in clinical routine and scientific situations. These novel imaging modalities enable an in vivo visualization of the quality of the cartilaginous structure and bone as well as all articular and periarticular tissues. Therefore, the limitations of radiographs in knee OA assessment could be overcome by these techniques. This review article should provide an insight into the most important radiological features of knee OA and their systematic visualization with different imaging approaches that can be used in clinical routine.

No signs of dose escalations of potent opioids prescribed after tibial shaft fractures: a study of Swedish National Registries.

BACKGROUND: The pattern of opioid use after skeletal trauma is a neglected topic in pain medicine. The purpose of this study was to analyse the long-term prescriptions of potent opioids among patients with tibial shaft fractures. METHODS: Data were extracted from the Swedish National Hospital Discharge Register, the National Pharmacy Register, and the Total Population Register, and analysed accordingly. The study period was 2005-2008. RESULTS: We identified 2,571 patients with isolated tibial shaft fractures. Of these, 639 (25%) collected a prescription for opioids after the fracture. The median follow-up time was 17 (interquartile range [IQR] 7-27) months. Most patients with opioid prescriptions after fracture were male (61%) and the median age was 45 (16-97) years. The leading mechanism of injury was fall on the same level (41%). At 6 and 12 months after fracture, 21% (95% CI 17-24) and 14% (11-17) were still being treated with opioids. Multiple Cox regression-analysis (adjusted for age, sex, type of treatment, and mechanism of injury) revealed that older patients (age >50 years) were more likely to end opioid prescriptions (Hazard ratio 1.5 [95% CI 1.3-1.9]). During follow-up, the frequency of patients on moderate and high doses declined. Comparison of the daily morphine equivalent dose among individuals who both had prescriptions during the first 3 months and the 6th month indicated that the majority of these patients (11/14) did not have dose escalations. CONCLUSIONS: We did not see any signs in registry-data of major dose escalations over time in patients on potent opioids after tibial shaft fractures.

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

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

Dual-mobility cups for revision due to instability are associated with a low rate of re-revisions due to dislocation: 228 patients from the Swedish Hip Arthroplasty Register.

BACKGROUND AND PURPOSE: Revision total hip arthroplasty (THA) due to recurrent dislocations is associated with a high risk of persistent instability. We hypothesized that the use of dual-mobility cups would reduce the risk of re-revision due to dislocation after revision THA. PATIENTS AND METHODS: 228 THA cup revisions (in 228 patients) performed due to recurrent dislocations and employing a specific dual-mobility cup (Avantage) were identified in the Swedish Hip Arthroplasty Register. Kaplan-Meier survival analysis was performed with re-revision due to dislocation as the primary endpoint and re-revision for any reason as the secondary endpoint. Cox regression models were fitted in order to calculate the influence of various covariates on the risk of re-revision. RESULTS: 58 patients (25%) had been revised at least once prior to the index cup revision. The surgical approach at the index cup revision was lateral in 99 cases (44%) and posterior in 124 cases (56%). Median follow-up was 2 (0-6) years after the index cup revision, and by then 18 patients (8%) had been re-revised for any reason. Of these, 4 patients (2%) had been re-revised due to dislocation. Survival after 2 years with the endpoint revision of any component due to dislocation was 99% (95% CI: 97-100), and it was 93% (CI: 90-97) with the endpoint revision of any component for any reason. Risk factors for subsequent re-revision for any reason were age between 50-59 years at the time of the index cup revision (risk ratio (RR) = 5 when compared with age > 75, CI: 1-23) and previous revision surgery to the relevant joint (RR = 1.7 per previous revision, CI: 1-3). INTERPRETATION: The risk of re-revision due to dislocation after insertion of dual-mobility cups during revision THA performed for recurrent dislocations appears to be low in the short term. Since most dislocations occur early after revision THA, we believe that this device adequately addresses the problem of recurrent instability. Younger age and prior hip revision surgery are risk factors for further revision surgery. However, problems such as potentially increased liner wear and subsequent aseptic loosening may be associated with the use of such devices in the long term.

Salvage of failed trochanteric and subtrochanteric fractures using a distally fixed, modular, uncemented hip revision stem.

BACKGROUND AND PURPOSE: Treatment options for failed internal fixation of hip fractures include prosthetic replacement. We evaluated survival, complications, and radiographic outcome in 30 patients who were operated with a specific modular, uncemented hip reconstruction prosthesis as a salvage procedure after failed treatment of trochanteric and subtrochanteric fractures. PATIENTS AND METHODS: We used data from the Swedish Hip Arthroplasty Register and journal files to analyze complications and survival. Initially, a high proportion of trochanteric fractures (7/10) were classified as unstable and 12 of 20 subtrochanteric fractures had an extension through the greater trochanter. Modes of failure after primary internal fixation were cutout (n = 12), migration of the femoral neck screw (n = 9), and other (n = 9). RESULTS: Mean age at the index operation with the modular prosthesis was 77 (52-93) years and the mean follow-up was 4 (1-9) years. Union of the remaining fracture fragments was observed in 26 hips, restoration of proximal bone defects in 16 hips, and bone ingrowth of the stem in 25 hips. Subsidence was evident in 4 cases. 1 patient was revised by component exchange because of recurrent dislocation, and another 6 patients were reoperated: 5 because of deep infections and 1 because of periprosthetic fracture. The cumulative 3-year survival for revision was 96% (95% CI: 89-100) and for any reoperation it was 83% (68-93). INTERPRETATION: The modular stem allowed fixation distal to the fracture system. Radiographic outcome was good. The rate of complications, however-especially infections-was high. We believe that preoperative laboratory screening for low-grade infection and synovial cultures could contribute to better treatment in some of these patients.

The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis. An analysis of 78,098 operations in the Swedish Hip Arthroplasty Register.

BACKGROUND AND PURPOSE: The effects of patient-related and technical factors on the risk of revision due to dislocation after primary total hip arthroplasty (THA) are only partly understood. We hypothesized that increasing the femoral head size can reduce this risk, that the lateral surgical approach is associated with a lower risk than the posterior and minimally invasive approaches, and that gender and diagnosis influence the risk of revision due to dislocation. PATIENTS AND METHODS: Data on 78,098 THAs in 61,743 patients performed between 2005 and 2010 were extracted from the Swedish Hip Arthroplasty Register. Inclusion criteria were a head size of 22, 28, 32, or 36 mm, or the use of a dual-mobility cup. The covariates age, sex, primary diagnosis, type of surgical approach, and head size were entered into Cox proportional hazards models in order to calculate the adjusted relative risk (RR) of revision due to dislocation, with 95% confidence intervals (CI). RESULTS: After a mean follow-up of 2.7 (0-6) years, 399 hips (0.5%) had been revised due to dislocation. The use of 22-mm femoral heads resulted in a higher risk of revision than the use of 28-mm heads (RR = 2.0, CI: 1.2-3.3). Only 1 of 287 dual-mobility cups had been revised due to dislocation. Compared with the direct lateral approach, minimally invasive approaches were associated with a higher risk of revision due to dislocation (RR = 4.2, CI: 2.3-7.7), as were posterior approaches (RR = 1.3, CI: 1.1-1.7). An increased risk of revision due to dislocation was found for the diagnoses femoral neck fracture (RR = 3.9, CI: 3.1-5.0) and osteonecrosis of the femoral head (RR = 3.7, CI: 2.5-5.5), whereas women were at lower risk than men (RR = 0.8, CI: 0.7-1.0). Restriction of the analysis to the first 6 months after the index procedure gave similar risk estimates. INTERPRETATION: Patients with femoral neck fracture or osteonecrosis of the femoral head are at higher risk of dislocation. Use of the minimally invasive and posterior approaches also increases this risk, and we raise the question of whether patients belonging to risk groups should be operated using lateral approaches. The use of femoral head diameters above 28 mm or of dual-mobility cups reduced this risk in a clinically relevant manner, but this observation was not statistically significant.

Surgical treatment of skeletal metastases in 31 melanoma patients.

The authors retrospectively studied 31 patients with malignant melanoma who were surgically treated for 34 skeletal metastases between 1987 and 2007. The aim was to evaluate the role of orthopaedic surgery and to identify factors related to survival. The patients were operated on for spinal cord compression (n = 12) and metastatic destruction in a long bone (n = 17), or other locations (n = 5). The median survival after surgery was 1.9 months (range: 0-40). The survival rate was 039 at 3 months, and 0.13 at 1 year. Four of 34 operations led to failure necessitating reoperation. A prolonged delay between diagnosis and surgery, radical excision, a solitary skeletal metastasis, radiotherapy, a perioperative lactate dehydrogenase (LDH) level < or = 8 microkat/L (p = 0.04) and a preoperative haemoglobin level > 11.5 mg/dL (p = 0.003) had a favourable prognostic impact. A vertebral localization was unfavourable. These prognostic factors may help identify which melanoma patients with symptomatic skeletal metastases will benefit from orthopaedic surgery. This study represents the largest reported cohort surgically treated for skeletal metastasis of malignant melanoma at a single institution.

Survival of uncemented acetabular monoblock cups: evaluation of 210 hips in the Swedish Hip Arthroplasty Register.

BACKGROUND AND PURPOSE: Monoblock acetabular cups represent a subtype of uncemented cups with the polyethylene liner molded into a metal shell, thus eliminating-or at least minimizing-potential backside wear. We hypothesized that the use of monoblock cups could reduce the incidence of osteolysis and aseptic loosening, and thus improve survival compared to modular designs. PATIENTS AND METHODS: We identified all 210 primary total hip arthroplasty (THA) procedures in the Swedish Hip Arthroplasty Register that used uncemented monoblock cups during the period 1999-2010. Kaplan-Meier and Cox regression analyses with adjustment for age, sex, and other variables were used to calculate survival rates and adjusted hazard ratios (HRs) of the revision risk for any reason. 1,130 modular cups, inserted during the same time period, were used as a control group. RESULTS: There was a nearly equal sex distribution in both groups. Median age at the index operation was 47 years in the monoblock group and 56 years in the control group (p < 0.001). The cumulative 5-year survival with any revision as the endpoint was 95% (95% CI: 91-98) for monoblock cups and 97% (CI: 96-98) for modular cups (p = 0.6). The adjusted HR for revision of monoblock cups compared to modular cups was 2 (CI: 0.8-6; p = 0.1). The use of 28-mm prosthesis heads rather than 22-mm heads reduced the risk of cup revision (HR = 0.2, CI: 0.1-0.5; p = 0.001). INTERPRETATION: Both cups showed good medium-term survival rates. There was no statistically significant difference in revision risk between the cup designs. Further review of the current patient population is warranted to determine the long-term durability and risk of revision of monoblock cup designs.

The time-averaged inflammatory disease activity estimates the progression of erosions in MRI of the sacroiliac joints in ankylosing spondylitis.

A method to estimate the individual ankylosing spondylitis (AS) patient radiological progression of semi-quantitative magnetic resonance imaging (MRI) changes in the sacroiliac joints has not been described yet, which this study examines. Inflammatory disease activity and MRIs of the sacroiliac joints of 38 patients with recent onset established AS were analyzed at baseline and during follow-up. Sacroiliac MRIs were semi-quantitatively assessed using a modification of the "Spondylarthritis Research Consortium of Canada" (SPARCC) method. In each patient, the annual inflammatory disease activity was estimated by the time-averaged C-reactive protein (CRP; mg/l), calculated as the area under the curve. The mean (SD) CRP decreased from 1.3 (1.8) at baseline to 0.5 (0.6) at follow-up MRI (p < 0.04), which has been performed after a mean (SD) disease course of 2.8 (1.5) years. The mean (SD) annual increase (∆) of SPARCC score from baseline to follow-up MRI was 0.4 (0.4). Baseline individual SPARCC sub-score for bone marrow edema did not statistically significantly correlate with individual ∆SPARCC sub-score for erosions (p = N.S.). The individual AS patient correlation between annual time-averaged inflammatory disease activity and each annual ∆SPARCC sub-scores was only statistically significant for erosions (p < 0.01; r = 0.71). Our results show that bone marrow edema and contrast-medium enhancement at baseline do not relate to the progression of erosions but the calculation of the individual patient annual time-averaged inflammatory disease activity allows to estimate the annual progression of erosions in sacroiliac MRIs of patients with AS.

Complications and survival after surgical treatment of 214 metastatic lesions of the humerus.

BACKGROUND: The humerus is the second most common long-bone site of metastatic bone disease. We report complications, risk factors for failure, and survival of a large series of patients operated on for skeletal metastases of the humerus. MATERIALS AND METHODS: This study was based on 208 patients treated surgically for 214 metastatic lesions of the humerus. Reconstructions were achieved by intramedullary nails in 148, endoprostheses in 35, plate fixation in 21, and by other methods in 10. RESULTS: The median age at surgery was 67 years (range, 29-87 years). Breast cancer was the primary tumor in 31%. The overall failure rate of the surgical reconstructions was 9%. The reoperation rate was 7% in the proximal humerus, 8% in the diaphysis, and 33% in the distal part of the bone. Among 36 operations involving an endoprosthesis, 2 were failures (6%) compared with 18 of 178 osteosynthetic devices (10%). In the osteosynthesis group, intramedullary nails failed in 7% and plate fixation failed in 22%. Multivariate Cox regression analysis showed that prostate cancer was associated with an increased risk of failure after surgery (hazard ratio, 7; P < 0.033). The cumulative survival after surgery was 40% (95% confidence interval [CI] 34-47) at 1 year, 21% (95% CI, 15-26) at 2 years, and 16% (95% CI, 12-19) at 3 years. CONCLUSIONS: Our method of choice is the cemented hemiprosthesis for pathologic proximal humeral fractures and interlocked intramedullary nail for lesions in the diaphysis. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate.