Malunion of a clavicle fracture caused thoracic outlet syndrome in a professional violinist.

Clavicle fractures are a common injury in adults. Most patients are treated non-operatively. In this case report, a 53-year-old professional violinist had a midt shaft clavicula fracture and was treated non-operatively. The fracture healed, but the patient developed thoracic outlet syndrome (TOS) and a venous thrombosis when playing violin. Surgery with restoration of the normal anatomy alleviated the symptoms and six months later she was symptom free and playing violin again. TOS is a rare complication to clavicle fractures and the treating doctors should be aware of the diagnosis.

Clavicle fractures do not increase the occurrence of later subacromial pain syndrome. A registry-based case-control study with 15-25 years of follow-up of 131.838 persons from the Danish National Patient Register.

Background: A clavicle fracture often changes the mechanical axes of the shoulder girdle due to displacement and shortening, potentially leading to scapular protraction and decreased subacromial space. If protraction of the scapula is a major risk factor for developing subacromial pain syndrome (SAPS), a previous clavicle fracture could increase the risk of later SAPS. The purpose of this study was to investigate if a previous clavicle fracture correlates with a higher occurrence or earlier diagnosis of SAPS. Methods: In this retrospective case-control study with data from the Danish National Patient Register, all persons aged 18-60 years, with any hospital contact due to a clavicle fracture (DS420) between January 1, 1996, and December 31, 2005, were identified as cases. For each case, five controls, matched on age and sex, were identified. Primary outcome was the first hospital contact with a SAPS diagnosis (DM751-755) registered more than 180 days following the fracture. Follow-up was until November 01, 2021. Results: 21.973 cases and 109.865 controls were included. The incidence of clavicle fractures was 76 fractures per 100.000 persons per year. Twenty-three percent were female. 1.640 (7.46%) cases and 8.072 (7.35%) controls received a SAPS diagnosis within the following 15-25 years, demonstrating no significant difference in the occurrence of SAPS (P = .56). The mean time from fracture to SAPS diagnosis was shorter for cases compared to controls (4040 vs. 4442 days, P < .001), and cases were slightly younger when receiving the diagnosis (51.3 vs. 53.6 years, P < .001). 1614 cases underwent surgical fixation. This subgroup had a statistically significant higher occurrence of later SAPS diagnosis (205 cases, 13%, P < .001). Conclusions: Persons with a previous clavicle fracture did not have an increased occurrence of receiving a SAPS diagnosis compared to matched controls. However, the diagnosis was given 1-2 years earlier for people with a previous fracture. Based on these findings, no strong argument for protraction of the scapula as a major risk factor for the development of SAPS was found.

[Traumatic isolated dislocation of the proximal tibiofibular joint is a rare injury].

Dislocation of the proximal tibiofibular joint should be promptly reduced when recognised in the emergency room. If closed reduction technique is unsuccessful, open reduction with the possibility of fixation should be performed. Currently, no consensus exists regarding the optimal post-reduction regime. We present a case report of a 30-year-old male who suffered a dislocation of the proximal tibiofibular joint during soccer. Closed reduction was successful, and the patient did not suffer from any sequalae later on.

Osteosynthesis with Parallel Implants in the Treatment of Femoral Neck Fractures: Minimal Effect of Implant Position on Risk of Reoperation.

BACKGROUND: The purpose of this study was to estimate the incidence of reoperation and the effect of implant position on the risk of reoperation within 12 months following osteosynthesis with use of parallel implants for femoral neck fractures. METHODS: From cases registered in the Danish Fracture Database, 1,206 consecutive surgeries for a primary femoral neck fracture treated with use of parallel implants during the period of December 2011 to November 2015, and having available radiographs and follow-up data, were reviewed. Data included age, sex, time to surgery, fracture classification, and American Society of Anesthesiologists (ASA) score. Fracture displacement, posterior tilt, the number of implants, posterior distance, calcar distance, tip-cartilage distance, and angulation of implants were measured on pre- and postoperative radiographs. Data on secondary surgeries were collected from the Danish Civil Registration System. The effects of the included variables on the risk of reoperation were evaluated using Cox regression analysis. RESULTS: The median age was 73 years (range, 21 to 102 years); in 69% of the cases, the patient was female. Two implants were used in 997 cases and 3 implants were used in 209. In 157 cases, the patient underwent reoperation within 1 year; in 228 cases, the patient died within 1 year. The median time to reoperation was 116 days. Patients <70 years of age were more likely to undergo reoperation (18.0% compared with 9.8%) but less likely to die (7.4% compared with 26.3%) than were patients ≥70 years of age. Female sex, higher ASA score, and displaced fractures were associated with increased risk of reoperation. Time to surgery was associated with increased risk of reoperation for displaced fractures only. Of the variables pertaining to the osteosynthesis, only insufficient fracture reduction, placement of the implants with an angle to the shaft of ≤125°, and femoral head perforation significantly increased the risk of reoperation. We found no effect of the posterior distance, the calcar distance, the tip-caput distance, or whether or not the implants were parallel. CONCLUSIONS: Insufficient reduction, varus position of the implants, and perforation of the femoral head cartilage were the only surgical factors influencing the risk of reoperation. Sufficient fracture reduction is perhaps more important than focusing on an optimal position of the implants. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

No association between surgical delay and mortality following distal femoral fractures. A study from the danish fracture database collaborators.

BACKGROUND: The purpose of this study was to investigate whether surgical delay or the educational level of surgeon is associated with early mortality in patients with distal femoral fractures. METHODS: 392 consecutive patients aged ≥50 years registered in the Danish Fracture Database for surgery of a non-pathological, closed, low-energy distal femoral fracture (AO33A-C) were included. Data included age, gender, American Society of Anaesthesiologists (ASA) score, type of fracture, educational level of surgeon and surgical delay. Educational level of surgeon was defined as "attending or above as surgeon", "attending or above as supervisor" or "below attending alone". Surgical delay was defined as hours (h) from radiological diagnostics until onset of surgery. Mortality data was provided by The Civil Registration System. Mortality rates were calculated using multiple logistical regression analysis. RESULTS: Mean age was 76 years (range 50-101), 79% of patients were female and 65% had an extra articular fracture (AO33A). 8% were operated within 12h, 33% within 24h, 67% within 48h and 83% within 72h. Educational level of surgeon was "attending or above as surgeon" in 56% of all cases and "attending or above as supervisor" in 33%. Mortality was 7.1% at day 30 and 12.5% at day 90. The logistical regression analysis did not demonstrate any association between surgical delay or educational level of surgeon and mortality. Increasing age, male gender and ASA score >2 significantly increased both 30-day and 90-day mortality. CONCLUSION: No association between surgical delay or educational level of surgeon and mortality was found. These findings do not support the development of guidelines for decreasing surgical delay in this population.

Lacking evidence for performance of implants used for proximal femoral fractures - A systematic review.

INTRODUCTION: Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark. METHOD: PubMed was searched for clinical studies on primary PFF with follow-up ≥12 months, reporting implant-related failure and evaluating one of following: DHS, CHS, HipLoc, Gamma3, IMHS, InterTan, PFN, PFNA or PTN. LIMITS: English language and publication date after 1st of January 1990. RESULTS: All studies were evidence level II or III. 30 publications for SHS were found: 13 of CHS, 15 of DHS and 2 of HipLoc. In total CHS was evaluated in 1110 patients (900 prospectively), DHS in 2486 (567 prospectively) and HipLoc in 251 (all prospectively). Fifty-four publications for nails were found: 13 of Gamma3, 7 of IMHS, 5 of InterTan, 10 of PFN, 24 of PFNA and 0 of PTN. In total Gamma3 was evaluated in 1088 patients (829 prospectively), IMHS in 1543 (210 prospectively), InterTan in 595 (585 prospectively), PFN in 716 (557 prospectively), PFNA in 1762 (1018 prospectively) and PTN in 0. CONCLUSIONS: The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide. Sporadic evaluation is not sufficient to identify long term problems. A systematic post market surveillance of implants used for fracture treatment, preferable by a national register, is necessary in the future.

Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators.

BACKGROUND: We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients. METHODS: We performed a retrospective analysis of prospectively collected data from the Danish Fracture Database and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture. Femoral head fracture (classified as OTA/AO 31C per the OTA/AO classification system), high-energy trauma, pathological fractures, multiple fractures, and surgeries performed with implants not commonly used were excluded. End points were adjusted odds ratios for thirty-day and ninety-day mortality. RESULTS: For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality. CONCLUSIONS: In this study, a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality. The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon. The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons.

miR-125b induces cellular senescence in malignant melanoma.

BACKGROUND: Micro RNAs (miRs) have emerged as key regulators during oncogenesis. They have been found to regulate cell proliferation, differentiation, and apoptosis. Mir-125b has been identified as an oncomir in various forms of tumours, but we have previously proposed that miR-125b is a suppressor of lymph node metastasis in cutaneous malignant melanoma. Our goal was therefore to further examine this theory. METHODS: We used in-situ-hybridization to visualise miR-125b expression in primary tumours and in lymph node metastasis. Then using a miRVector plasmid containing a miR-125b-1 insert we transfected melanoma cell line Mel-Juso and then investigated the effect of the presence of a stable overexpression of miR-125b on growth by western blotting, flow cytometry and ß-galactosidase staining. The tumourogenicity of the transfected cells was tested using a murine model and the tumours were further examined with in-situ-hybridization. RESULTS: In primary human tumours and in lymph node metastases increased expression of miR-125b was found in single, large tumour cells with abundant cytoplasm. A stable overexpression of miR-125b in human melanoma cell line Mel-Juso resulted in a G0/G1 cell cycle block and emergence of large cells expressing senescence markers: senescence-associated beta-galactosidase, p21, p27 and p53. Mel-Juso cells overexpressing miR-125b were tumourigenic in mice, but the tumours exhibited higher level of cell senescence and decreased expression of proliferation markers, cyclin D1 and Ki67 than the control tumours. CONCLUSIONS: Our results confirm the theory that miR-125b functions as a tumour supressor in cutaneous malignant melanoma by regulating cellular senescence, which is one of the central mechanisms protecting against the development and progression of malignant melanoma.