AMIC Procedure for Treatment of Osteochondral Lesions of Talus-A Systematic Review of the Current Literature.

Osteochondral lesions of talus are a common injury where surgery is indicated in case of failed non-operative treatment or displaced lesions. Many studies have been conducted on the effectiveness of the AMIC procedure. The goal of our study is to create an overview of the current literature. A systematic search adhering to the PRISMA guidelines was conducted in PubMed (MEDLINE) and EMBASE on May 27, 2020. All included studies were evaluated according to the modified Coleman Methodology Score and information on study type, patient numbers, age, follow-up period, grade, location and size of the lesion, study in- and exclusion criteria, associated surgery, surgical technique, scaffold- and fixation technique, postoperative restrictions, reoperation rates, study outcome score, rehabilitation program, and surgical complications was extracted. Ninety-six studies were identified with 18 studies being included in our analysis. The overall quality of the literature was fair with no studies being graded as excellent. Data on preoperative evaluation and surgical technique, complication and reoperation rates, postoperative management and study outcome was extracted in order to create an overview of the current literature. The literature supports the use of the AMIC procedure as an effective treatment for osteochondral lesions of talus. Great heterogeneity exists and comparative studies are missing. While the number of studies on the topic is increasing further are needed and especially with optimized design.

[Surgical treatment options of foot deformities caused by neuromuscular disorders].

Many neuromuscular diseases can lead to paresis and/or spasticity of the peripheral muscles. Due to an unbalance between agonists and antagonists deformities of the foot and ankle may develop. These deformities can often be handled by nonoperative measures but in some patients the effect is insufficient. In these cases, surgical treatment with tendon transfers, osteotomies or arthrodesis can lead to satisfying results. The purpose of this review is to create an overview of the treatment concepts and options for these diseases.

Overnight Admission After Total Ankle Replacement: Is It Safe?

To evaluate readmission, complication, and nonscheduled contact rates to the out-patient clinic within the first 3 months following total ankle replacement in patients planned for overnight admission. Data were collected retrospectively on all patients treated during the period the December 11, 2015 to the December 1, 2019 with 3 months of follow-up for all patients. In the study 116 patients were included. No difference in patient characteristics, readmission rates, complication rates or number of nonscheduled contacts to the outpatient clinic was found between patients discharged after 1 day when compared to those admitted >1 day. Around 58.6% was discharged as planned. The overall readmission and complication rates were 2.6% and 6.0% respectively, 20.7% had a nonscheduled contact to the out-patient clinic. No differences in prevalence of the different complications, reasons for readmission or reasons for contact to the out-patient clinic were found between overnight admission and inpatient admission. Total ankle placement with overnight admission is safe, but patient selection with a thorough plan for analgesics after discharge and optimal cast appliance is necessary.

[Ankle arthrosis].

Symptomatic ankle arthrosis affects 1-4% of the population, and the most common aetiology is post-traumatic. Symptoms include pain, swelling and reduced range of motion. Diagnosis is based on weight-bearing X-rays of the ankle joint, and treatment depends on the arthrosis grade and patient characteristics. Non-operative therapy, i.e. physiotherapy, analgesics, injection therapy and/or braces/orthoses is first-line treatment, as we argue in this review. Arthroscopy can be an effective treatment for some patients, but in case of severe arthrosis, osteotomies, total ankle replacement or arthrodesis may be necessary.

The Effect of a Single Hyaluronic Acid Injection in Ankle Arthritis: A Prospective Cohort Study.

Nonoperative measures are often used as first line treatment in ankle osteoarthritis. One of these measures consists of hyaluronic acid injections in the affected ankle joint, but efficiency of this treatment is uncertain. The purpose of the study was to evaluate the effect on Self-reported Foot and Ankle Score, visual analog scale score at rest, and visual analog scale score at activity 6 months after a single dose of hyaluronic acid in patients with ankle osteoarthritis. Patients were included from December 2017 to March 2019. A single intra-articular injection of Cingal or MonoVisc was administered. Age, gender, osteoarthritis-grade, Self-reported Foot and Ankle Score, visual analog score at activity, and at rest before injection and after 6 months was registered. A total of 33 patients were included, with 14 lost to follow-up. Four were treated with MonoVisc and were excluded to reduce confounding. The remaining 15 patients were included for analysis. Median Self-reported Foot and Ankle Score remained unchanged (p = .06), whereas visual analog score at activity went from 7 to 6 (.02) and visual analog score at rest was reduced from 4 to 3 (.02). Subgroup analysis on arthrosis grade (grade I-II and III-IV) showed no statistically significant changes for all variables even though patients with grade III-IV arthrosis seemed to benefit more from the treatment. The results indicate that a single injection of hyaluronic acid is insufficient to produce at clinically relevant response after 6 months even though there is a high risk of underpowering because of a small patient population.

Pre-fracture medication use as a predictor of 30-day mortality in hip fracture patients: an analysis of 141,201 patients.

PURPOSE: To evaluate the predictive value of pre-fracture medication usage on 30-day mortality following a hip fracture. METHODS: Information on age, sex, fracture type, time of death and Charlson co-morbidity index (CCI) was collected from the Danish National Patient Registry on all patients above 60 years, sustaining a hip fracture during the period January 1995 to December 2013. Information on drug usage was obtained from the Danish National Prescription Database. Hazard ratios were calculated with 30-day mortality as the outcome. A univariate and 3 multivariate analyses were conducted with increasing adjustments, starting with age, sex and fracture type, adding co-morbidity and dose in the latter. RESULTS: 141,201 patients were included and a total of 12 drugs/drug groups were identified for analysis. Increased mortality was evident in all analyses for antiarrhythmics, beta blockers, proton pump inhibitors, loop diuretics, opioids, acetaminophen and for psycholeptics. For ACE-inhibitors, increased mortality was found in all analyses, except after adjustment for co-morbidity and dose. For thiazide diuretics, a significantly reduced mortality was evident in all but the univariate analyses while NSAIDs and statins were associated with a significantly reduced mortality in all analyses. For calcium channel blockers, an insignificant decrease was found after adjustment for dose. Further analysis showed a dose-response relationship for all drugs except ACE-inhibitors and calcium channel blockers. CONCLUSION: The study shows a correlation between pre-fracture usage of certain drugs and 30 day mortality after a hip fracture.

Excess mortality following hip fracture in patients with diabetes according to age: a nationwide population-based cohort study of 154,047 hip fracture patients.

OBJECTIVE: to test the hypothesis that excess mortality conferred by diabetes following hip fracture decreases with advancing age. METHODS: a nationwide population-based cohort study including 154,047 patients who were admitted with a hip fracture in Denmark from 1996 to 2012. Information on hip fracture diagnosis, diabetes, other comorbidities, and the primary outcome all-cause mortality was collected using the national Danish health registries. The association between diabetes and all-cause mortality according to age was assessed using Cox proportional hazards regression in the age categories: <50, 50-59, 60-69, 70-79, 80-89 and ≥90 years. RESULTS: during a median follow-up of 3 years (interquartile range: 1-6 years, 603,091 person-years) 114,990 died from any cause. In total, 8% (n = 12,158) of the patients had diabetes at baseline and had unadjusted, and age, sex and Charlson Comorbidity Index adjusted hazard ratios for all-cause mortality of 1.19 (95% confidence interval: 1.16-1.21) and 1.14 (1.12-1.17) as compared to patients without diabetes. The sex and Charlson Comorbidity Index adjusted hazard ratios according to age were 1.64 (1.34-2.02) for patients <50 years, 1.26 (1.12-1.40) for patients 50-59 years, 1.21 (1.13-1.29) for patients 60-69 years, 1.11 (1.07-1.16) for patients 70-79 years, 1.10 (1.07-1.14) for patients 80-89 years and 1.09 (1.02-1.16) for patients ≥90 years. There was a statistically significant interaction between diabetes and age (P < 0.001). CONCLUSIONS: diabetes is associated with excess mortality following hip fracture across all ages, but the excess mortality decreases with advancing age.

Temporal trends in hip fracture incidence, mortality, and morbidity in Denmark from 1999 to 2012.

Background and purpose - While development in hip fracture incidence and mortality is well examined, none has yet looked at the temporal trends regarding prevalence of co-morbidities. Therefore we investigated changes in incidence of first hip fracture, co-morbidity prevalence, 30 day- and 1-year mortality in hip fracture patients in the Danish population during the period 1999 to 2012. Patients and methods - Patients >18 years admitted with a fractured hip in Denmark between 1996 and 2012 were identified with data for the period 1999-2012 being analyzed regarding prevalence of co-morbidities, incidence, and mortality. Results - 122,923 patients were identified. Incidence in the whole population declined but sex-specific analysis showed no changes for men. For the whole study population, 30-day and 1-year mortality remained unchanged. Age at time of first hip fracture also remained unchanged. Of the included co-morbidities a decrease in prevalence of malignancy and dementia in women was found while there was an increase in the prevalence of all remaining co-morbidities, except hemi- or paraplegia for both sexes, rheumatic diseases for women, and for men diabetes with complications, myocardial infarction, AIDS/HIV, and malignancy. Interpretation - While hip fracture incidence declined for women it was unchanged for men; likewise, 30-day and 1-year mortality rates together with age at first fracture remained unchanged. When these results are compared with the relatively large increase in the prevalence of co-morbidities, it does not seem likely that the increased disease burden is affecting either the incidence or the mortality.

Opioid Usage During Admission in Hip Fracture Patients-The Effect of the Continuous Femoral Nerve Block.

INTRODUCTION: The aim of this study was to investigate whether there was a difference in opioid usage during admission for hip fracture patients with continuous femoral nerve block (cFNB) when compared to patients nonfemoral nerve block (nFNB). METHODS AND MATERIALS: Patients were identified from the local database on all hip fracture patients admitted to Bispebjerg University Hospital, Denmark. Four hundred fifty-six hip fracture patients were included during the period September 2008 to October 2010. RESULTS: Three hundred sixty-six hip fracture patients had cFNB. The mean time with cFNB was 3.4 days. There were no significant differences in gender, length of stay, time to surgery, mortality rate, in-hospital falls, or resurgery rates during admission between the 2 groups. The nFNB group had an insignificant higher use of morphine as needed during the first 5 days of admission (nFNB: 53.1 mg, 95% confidence interval [CI]: 34.4-71.7; cFNB: 47.7 mg, 95% CI: 40.7-64.3; P = .54) and during the whole admission (cFNB: 34.3 mg, 95% CI: 23.2-45.5; cFNB: 30.3 mg, 95% CI: 26.6-33.0; P = .4). Some 8.47% of the total morphine consumption during admission was morphine as needed for the nFNB group and 9.89% for the cFNB group. CONCLUSION: Patients with cFNB did only have a marginally lower opioid usage during admission when compared to patients without the block, with no significance between the 2 groups. This could indicate that the cFNB is an ineffective analgesic strategy, especially in the postoperative period, but larger randomized studies are needed in order to clarify this.

Temporal trends in the use of antithrombotics at admission.

Background and purpose - Currently, no clear evidence exists on the pattern of use of antithrombotics at admission in hip fracture patients and how this has changed over time. We investigated temporal trends in-and factors associated with-the use of antithrombotics in patients admitted with a fractured hip. Patients and methods - This was a population-based cohort study including all patients aged 18 years or above who were admitted with a hip fracture in Denmark from 1996 to 2012. The Danish national registries were used to collect information on medication use, vital status, and comorbidity. Results - From 1996 to 2012, the proportion of patients using antithrombotics in general increased by a factor of 2.3 from 19% to 43% (p < 0.001). More specifically, the use of anticoagulants increased by a factor of 6.8 and the use of antiplatelets increased by a factor of 2.1. When we adjusted for possible confounders, the use of antithrombotics still increased for every calendar year (relative risk (RR) = 1.03, CI: 1.03-1.04; p < 0.001). Age, sex, and Charlson comorbidity index were all associated with the use of antithrombotics (all p < 0.001). Interpretation - The proportion of hip fracture patients using antithrombotics at admission has increased substantially in Denmark over the last 2 decades. This highlights the need for evidence-based guidelines on how to handle patients using antithrombotics to ensure safe surgery and to avoid surgical delay.

Colles' fractures and osteoporosis--A new role for the Emergency Department.

PURPOSE: In Denmark, guidelines from the Danish Orthopedic Society recommend that patients older than 65 years who sustain a Colles' fracture should be referred to assessment of underlying osteoporosis. An assessment of referral rates at our hospital during the period October 2010-September 2013 showed that none were referred. Due to this, an automatic out-patient referral system for assessment of underlying osteoporosis was established. With this system, patients are referred directly from the Emergency Department (ED). The purpose of this study was to assess how effective this new referral system was at improving referral rates for assessment of osteoporosis and to evaluate how many more cases of osteoporosis that was identified with this practice during the period October 2013-September 2014. METHOD: The automatic referral system for evaluation of osteoporosis in patients 65 years and above without known osteoporosis, living in the catchment area and sustaining a low energy distal forearm fracture was established in October 2013. With the new system, patients were referred directly from the ED for evaluation of osteoporosis at the osteoporosis out-patient department at the hospital. The system was evaluated for the period October 2013-September 2014. For comparison data was collected on the same patient group for the 3 years preceding the system. RESULTS: Before the automatic system none were referred for evaluation of osteoporosis and thus none were diagnosed. After introduction of the system 100% were referred, 73.26% were examined and 65.08% of these were found to have osteoporosis. Anti-osteoporotic treatment was initiated in all but 4.88% of the patients. CONCLUSION: The results show that this type of automatic referral system can be an effective way of increasing the number of patients diagnosed with and treated for osteoporosis. It also shows that involvement of the ED in the screening for osteoporosis can be an effective way of increasing referral rates leading to higher rates of diagnosed osteoporosis. The early identification and initiating of treatment might result in a lower rate of secondary and potentially more severe osteoporotic fractures.

Opioids in hip fracture patients: an analysis of mortality and post hospital opioid use.

OBJECTIVE: The aim of this study was to investigate the use of opioids among hip fracture patients, and the potential relation between perioperative prescription of opioids, mortality and chronic opioid use. The purpose of this study was to investigate the use of opioids among hip fracture patients postoperatively and 90- and 180 days after discharge. The study also analysed predictors of early death at 30-, 90 and 365 days after discharge. METHODS: We present data from the Orthopaedic Department at Bispebjerg University Hospital from 30 May 2010 and 31 March 2011 on 416 consecutively admitted hip fracture patients. Three patients died before surgery and were excluded from the analyses. Data were collected through medical records, hospital and national databases. Medication use was analysed before admission, at 3 and 6 months. Mortality data were analysed at 30 days, 6 months and 1 year. RESULTS: 24% were opioid users at admission, of whom 13% had an active malignant disease and 20% had been diagnosed with osteoporosis. 95% received opioids during admission, and 81% received a prescription for opioids at discharge. This fraction decreased to 36% at 3 months and 30% at 6 months. 2.9% of previous opioid naïve patients remained users at 6 months. Opioid use prior to admission and a pre-existing diagnosis of osteoporosis were the most significant factors associated with continued use at 3 and 6 months. The 30-day mortality was 10% and 1-year mortality was 27%. Mortality was associated with high age, ASA score>2, active cancer, high creatinine and leucocytosis. We found no association between opioids and mortality. CONCLUSION: The results of our study indicate no general reason to refrain from prescribing opioids to hip fracture patients based on a fear of potential abuse or increased mortality.

Daily number of fractures is associated with road temperature in an urban area.

INTRODUCTION: Different factors related to winter are known to influence the fracture incidence, but little is known about the effect of road surface temperature. This study examines the association between road surface temperature and the daily number of fractures in an urban area during two winters. MATERIAL AND METHODS: Retrospective data collection was conducted on all patients treated at Bispebjerg Hospital, Denmark, for a humeral, ankle, distal radius or hip fracture during the periods October to April 2009/2010 and 2010/2011. Patients were grouped according to age into the following categories: < 15, 15-30, 30-45, 45-60 and > 60 years. Data on road surface temperature (Tp.) were obtained from The Danish Road Directorate and grouped into the following categories: Days with Tp. > 0 °C, Tp. < 0 °C, Tp. > -5 °C, Tp. < -5 °C and ice alert (IA). RESULTS: A total of 4,892 patients (4,938 fractures) were treated during the study periods. The daily number of distal radius, humeral and ankle fractures increased significantly with decreasing road surface temperature and the presence of IA. For hip fractures no significant association was found. Decreasing temperature was associated with a significant decrease in the daily number of fractures for patients < 15 years, whereas patients > 30 years experienced a significant increase. CONCLUSION: Decreasing road temperature results in increased numbers of all fractures except hip fractures. Low temperatures is a risk factor for patients > 30 years and a protective factor for patients < 15 years. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Preoperative factors associated with red blood cell transfusion in hip fracture patients.

INTRODUCTION: Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients. METHOD: The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database. RESULTS: Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion. CONCLUSION: Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.

Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview.

BACKGROUND AND PURPOSE: Widely different metal ion concentrations in blood and serum have been reported with metal-on-metal (MoM) implants. We reviewed the literature on blood and serum ion concentrations of chromium (Cr) and cobalt (Co) following various MoM hip arthroplasties. METHODS: Studies were searched for in the Medline database, Embase, and the Cochrane Database of Systematic Reviews. Highest mean or median ion concentrations of Cr and Co after a minimum of 1 year of follow-up were extracted and grouped according to sample- and articulation type, and average values were calculated. RESULTS: 43 studies were included and 16 different MoM implants were identified. For the different types of bearings, average ion concentrations and range were calculated from the mean or median ion concentration. The average Cr concentration ranged between 0.5 and 2.5 µg/L in blood and between 0.8 and 5.1 µg/L in serum. For Co, the range was 0.7-3.4 µg/L in blood and 0.3-7.5 µg/L in serum. INTERPRETATION: When the average blood ion concentrations calculated for the different implants, together with the concentrations measured in the individual studies, were compared with the upper acceptable limit for Cr and Co in blood, no clear pattern was recognized. Furthermore, we were unable to detect any clear difference in ion concentrations between different types of implants (THA and resurfacing).