[Lumbar disc prosthesis, a high risk treatment for low back pain.] / Diskprotes ­ en riskabel behandling av ländryggssmärta.

When surgery is needed for chronic low back pain, replacement of the degenerated and potential pain generating disc with a prosthesis often gives good short-term pain relief. However, there is no evidence of the clinical superiority of prosthesis compared with other treatments. Disc prosthesis is associated with considerable risks of late severe complications, especially in revision surgery. The method has been suggested as a treatment for young active patients, which is highly questionable considering  the risk of late severe adverse events and complex revision surgery. Globally the method is declining and in many health care financing models it is not an approved treatment. In Sweden, the use of disc prosthesis is increasing.

The trend of radiological severity of hip fractures over a 30 years period: a cohort study.

BACKGROUND: Despite advances in operative techniques and preoperative care, proximal femur fractures (PFF) still represent a great public health problem. Displacement and fracture stability have been assumed as important determinants of treatment modality and outcome in such fractures. Purpose of this study was to determine whether the radiological severity of PFF fractures has increased over time. METHODS: In a cohort study, the plain radiographs of all patients with PFF aged over 50 years who were admitted to Umeå University Hospital in 1981/82, 2002 and 2012 were recruited to examine the types of fractures. RESULTS: The ratio of undisplaced to displaced femoral neck (FN) fractures was 30 to 70% in 1981/82, 28 to 72% in 2002 and 25 to 75% in 2012. The ratio of stable to unstable intertrochanteric (IT) fractures was 64 to 36% in 1981/82, 68 to 32% in 2002 and 75 to 25% in 2012. The ratio of simple to comminute subtrochanteric fractures was 35 to 65% in 1981/82, 16 to 84% in 2002 and 12 to 88% in 2012. In both FN and IT fractures we found no statistical difference among these 3 study periods, p = 0.67 and p = 0.40. In subtrochanteric fractures we saw a tendency towards more comminute subtrochanteric fractures (1981/82 to 2012), p = 0.09. CONCLUSIONS: We found no significant increment in the radiological severity of FN and IT over a 30 years' period. However, there was tendency towards an increase in comminute subtrochanteric fractures.

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial.

INTRODUCTION: The number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment. AIM: To investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia. PATIENTS AND METHODS: In this randomised controlled trial involving patients aged ≥70years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered. RESULTS: The study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9)years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12h compared with controls (p<0.001 and p=0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3±4.0 vs. 5.7±5.2mg, p<0.001) and in the subgroup with dementia (2.1±3.3 vs. 5.8±5.0mg, p<0.001). CONCLUSION: Patients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.

Trauma recidivism at an emergency department of a Swedish medical center.

BACKGROUND: To inform targeted prevention, we studied patterns of trauma recidivism and whether a first injury predicts the risk for a recurrent injury. METHODS: In a population-based study of 98,502 adult injury events 1999-2012, at the emergency department of Umeå University Hospital, Sweden, we compared non-recidivists with recidivists in terms of patients' sex, age, type of injury and severity of the injury. RESULTS: Thirty-six percent of all patients suffered recurrent injuries, which were associated with a higher proportion of inpatient care and more hospital days. Young men and elderly women were at the highest risk for trauma recidivism. At 20 to 24 years, men had a 2.4 (CI 95 % 2.3-2.5) higher risk than women, a 90 years old woman had almost a 10-fold higher risk for another moderate/severe injury than a 20 years old one. A fracture were associated with a hazard ratio of 1.28 (CI 95 % 1.15-1.42) among men younger than 65 years and 1.31 (CI 95 % 1.12-1.54) for men older than 65 years for a subsequent moderate/severe injury. For women younger than 65 years a fracture was associated with a hazard ratio of 1.44 (CI 95 % 1.28-1.62) for a subsequent moderate/severe injury. A sprain carries a higher risk for a new moderate/severe injury for both men and women and in both age groups; the hazard ratio was 1.13 (CI 95 % 1.00-1.26) for men younger than 65 years, 1.42 (CI 95 % 1.01-1.99) for men older than 65 years, 1.19 (CI 95 % 1.05-1.35) for women younger than 65 years and 1.26 (CI 95 % 1.02-1.56) for women older than 65 years. A higher degree of injury severity was associated with a higher risk for a new moderate/severe injury. CONCLUSION: Trauma recidivism is common and represents a large proportion of all injured. Age and sex are associated with the risk for new injury. Injury types and severity, also have implications for future injury.

Hip fracture risk and cadmium in erythrocytes: a nested case-control study with prospectively collected samples.

Several studies have investigated the relation between bone mass density and cadmium exposure, but only few studies have been performed on fractures and biomarkers of cadmium. This study analyzed the association between hip fracture risk and cadmium in erythrocytes (Ery-Cd). Prospective samples from the Northern Sweden Health and Disease Study's biobank were used for 109 individuals who later in life had sustained a low-trauma hip fracture, matched with two controls of the same age and gender. The mean concentration of Ery-Cd (±SD) in case samples was 1.3 ± 1.4 versus 0.9 ± 1.0 µg/L in controls. The odds ratio (OR) was 1.63 [95% confidence interval (CI) 1.10-2.42] for suffering a hip fracture for each microgram per liter increase in Ery-Cd. However, when taking smoking into consideration (never, former, or current), neither Ery-Cd nor smoking showed a statistically significant increase in fracture risk. Using multiple conditional logistic regression with BMI, height, and smoking, the estimated OR for a 1-µg/L increase in Ery-Cd was 1.52 (95% CI 0.77-2.97). Subgroup analysis showed an increased fracture risk among women (OR = 1.94, 95% CI 1.18-3.20, for a 1 µg/L increase), which also remained in the multiple analysis (OR = 3.33, 95% CI 1.29-8.56). This study shows that fracture risk is associated with Ery-Cd. It is, however, not possible to draw firm conclusions on whether cadmium is the causal factor or whether other smoking-related factors cause this association. Subgroup analysis shows that cadmium is a risk factor for hip fracture among women.

A genome-wide copy number association study of osteoporotic fractures points to the 6p25.1 locus.

BACKGROUND: Osteoporosis is a systemic skeletal disease characterised by reduced bone mineral density and increased susceptibility to fracture; these traits are highly heritable. Both common and rare copy number variants (CNVs) potentially affect the function of genes and may influence disease risk. AIM: To identify CNVs associated with osteoporotic bone fracture risk. METHOD: We performed a genome-wide CNV association study in 5178 individuals from a prospective cohort in the Netherlands, including 809 osteoporotic fracture cases, and performed in silico lookups and de novo genotyping to replicate in several independent studies. RESULTS: A rare (population prevalence 0.14%, 95% CI 0.03% to 0.24%) 210 kb deletion located on chromosome 6p25.1 was associated with the risk of fracture (OR 32.58, 95% CI 3.95 to 1488.89; p = 8.69 × 10(-5)). We performed an in silico meta-analysis in four studies with CNV microarray data and the association with fracture risk was replicated (OR 3.11, 95% CI 1.01 to 8.22; p = 0.02). The prevalence of this deletion showed geographic diversity, being absent in additional samples from Australia, Canada, Poland, Iceland, Denmark, and Sweden, but present in the Netherlands (0.34%), Spain (0.33%), USA (0.23%), England (0.15%), Scotland (0.10%), and Ireland (0.06%), with insufficient evidence for association with fracture risk. CONCLUSIONS: These results suggest that deletions in the 6p25.1 locus may predispose to higher risk of fracture in a subset of populations of European origin; larger and geographically restricted studies will be needed to confirm this regional association. This is a first step towards the evaluation of the role of rare CNVs in osteoporosis.

Early diagnosis and treatment is crucial for neurological recovery after surgery for metastatic spinal cord compression in prostate cancer.

BACKGROUND: Spinal cord compression is an oncological and surgical emergency. Delays in referral and diagnosis may influence functional outcome. It is therefore important to identify patients who will regain or maintain the ability to walk after surgery. The aim of the present study was to examine current practice for referral and diagnosis of prostate cancer patients with spinal cord compression and to identify prognostic factors for neurological outcome after surgery. PATIENTS AND METHODS: The study includes 68 consecutive patients with prostate cancer who underwent surgery due to neurological compromise. Intervals from onset of neurological symptoms to referral, diagnosis, and treatment were analyzed in relation to functional outcome. The prognostic significance of preoperative clinical parameters on gait function one month after surgery was evaluated. RESULTS: Patients who were referred from local hospitals had longer delay to surgery than those who directly presented to the cancer center (p = 0.004). The rate of diagnosis with MRI increased through the week and peaked on Friday, with few patients being diagnosed during weekends. The ability to walk before surgery, hormone-naive prostate cancer, and/or shorter time from loss of ambulation were associated with more favorable neurological outcome. In patients with hormone-refractory disease who were unable to walk before surgery regaining ambulation was associated with: duration of paresis < 48 hours (p = 0.005), good preoperative performance status (p = 0.04), preoperative PSA serum level < 200 ng/ml (p = 0.03), and surgery with posterior decompression and stabilization (p = 0.03). CONCLUSION: Early diagnosis and rapid treatment of spinal cord compression in prostate cancer patients is crucial for neurological recovery. Raising awareness of the condition among patients at risk and among physicians is of outmost importance as well as improving local and regional guidelines for treatment.

Quantitative proteomic analysis of eight cartilaginous tissues reveals characteristic differences as well as similarities between subgroups.

Human synovial joints display a characteristic anatomic distribution of arthritis, e.g. rheumatoid arthritis primarily affects the metacarpophalangeal and proximal finger joints, but rarely the distal finger joints, whereas osteoarthritis occurs in the distal and proximal finger joints. Pelvospondylitis has a selective localization to the spine and sacroiliac joints. Is this tropism due to differences between the cartilages at the molecular level? To substantiate this concept the present study provides a background detailed compositional analysis by relative quantification of extracellular matrix proteins in articular cartilages, meniscus, intervertebral disc, rib, and tracheal cartilages on samples from 5-6 different individuals using an optimized approach for proteomics. Tissue extraction followed by trypsin digestion and two-dimensional LC separations coupled to tandem mass spectrometry, relative quantification with isobaric labeling, iTRAQ(TM), was used to compare the relative abundance of about 150 proteins. There were clear differences in protein patterns between different kinds of cartilages. Matrilin-1 and epiphycan were specific for rib and trachea, whereas asporin was particularly abundant in the meniscus. Interestingly, lubricin was prominent in the intervertebral disc, especially in the nucleus pulposus. Fibromodulin and lumican showed distributions that were mirror images of one other. Analyses of the insoluble residues from guanidine extraction revealed that a fraction of several proteins remained unextracted, e.g. asporin, CILP, and COMP, indicating cross-linking. Distinct differences in protein patterns may relate to different tissue mechanical properties, and to the intriguing tropism in different patterns of joint pathology.

The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders.

BACKGROUND: We evaluated the results of the May modification of the Bristow-Latarjet procedure ("coracoid in standing position") in 319 shoulders with respect to (1) coracoid healing and position and (2) surgical treatment of the joint capsule. METHODS: From 1980 until 2004, all shoulders with a Bristow-Latarjet repair were registered at our hospital. This study consists of 3 different cohorts with respect to follow-up. Series 1, 118 shoulders operated on during 1980 through 1985, had 15 years' radiographic and clinical follow-up. Series 2, 167 shoulders that had surgery during 1986 through 1999, underwent retrospective follow-up by a questionnaire and scores--Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder and Hand; and Subjective Shoulder Value--after 10 to 23 years. Series 3, 34 shoulders treated during 2000 through 2004, with an added modified Bankart repair ("capsulopexy") in 33 shoulders, were prospectively followed up for 5 to 8 years with the same questionnaire and scores as series 2. RESULTS: Of 319 shoulders, 16 (5%) had 1 or more redislocations and 3 of these (1%) had revision surgery because of remaining instability. One or more subluxations were reported in 41 shoulders (13%). The worst scores were found in 16 shoulders with 2 or more subluxations (P < .001). Radiographs showed bony healing in 246 of 297 shoulders (83%), fibrous union in 34 (13%), migration by 0.5 cm or more in 14 (5%), and no visualization in 3 (1%). Five of six shoulders that had the transplant positioned 1 cm or more medial to the glenoid rim had redislocations (83%, P = .001). Shoulders with migrated transplants did not differ from those with bony or fibrous healing with respect to redislocations and subluxations. When just a horizontal capsular shift was added to the transfer, the recurrence rate (redislocations or subluxations) decreased, with 2 of 53 (4%)compared with 37 of 208 (18%) with just anatomic closure of the capsule (P = .005), and the Western Ontario Shoulder Instability Index score improved (92 vs 85.6, P = .048). In total, for 307 of 319 shoulders (96%), patients were satisfied or very satisfied at final follow-up. CONCLUSION: The open Bristow-Latarjet procedure yields good and consistent results, with bony fusion of the coracoid in 83%. A position of the coracoid 1 cm or more medial to the rim meant significantly more recurrences. The rate of recurrences decreased and subjective results improved when a horizontal capsular shift was added to the coracoid transfer.

Retinoids stimulate periosteal bone resorption by enhancing the protein RANKL, a response inhibited by monomeric glucocorticoid receptor.

Increased vitamin A (retinol) intake has been suggested to increase bone fragility. In the present study, we investigated effects of retinoids on bone resorption in cultured neonatal mouse calvarial bones and their interaction with glucocorticoids (GC). All-trans-retinoic acid (ATRA), retinol, retinalaldehyde, and 9-cis-retinoic acid stimulated release of (45)Ca from calvarial bones. The resorptive effect of ATRA was characterized by mRNA expression of genes associated with osteoclast differentiation, enhanced osteoclast number, and bone matrix degradation. In addition, the RANKL/OPG ratio was increased by ATRA, release of (45)Ca stimulated by ATRA was blocked by exogenous OPG, and mRNA expression of genes associated with bone formation was decreased by ATRA. All retinoid acid receptors (RARα/ß/γ) were expressed in calvarial bones. Agonists with affinity to all receptor subtypes or specifically to RARα enhanced the release of (45)Ca and mRNA expression of Rankl, whereas agonists with affinity to RARß/γ or RARγ had no effects. Stimulation of Rankl mRNA by ATRA was competitively inhibited by the RARα antagonist GR110. Exposure of calvarial bones to GC inhibited the stimulatory effects of ATRA on (45)Ca release and Rankl mRNA and protein expression. This inhibitory effect was reversed by the glucocorticoid receptor (GR) antagonist RU 486. Increased Rankl mRNA stimulated by ATRA was also blocked by GC in calvarial bones from mice with a GR mutation that blocks dimerization (GR(dim) mice). The data suggest that ATRA enhances periosteal bone resorption by increasing the RANKL/OPG ratio via RARα receptors, a response that can be inhibited by monomeric GR.

Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up.

BACKGROUND: In 2 Swedish hospitals, 88 consecutive shoulders underwent Bankart repair (B), and 97 consecutive shoulders underwent Bristow-Latarjet repair (B-L) for traumatic anterior recurrent instability. MATERIALS AND METHODS: Mean age at surgery was 28 years (B-L group) and 27 years (B group). All shoulders had a follow-up by letter or telephone after a mean of 17 years (range, 13-22 years). The patients answered a questionnaire and completed the Western Ontario Shoulder Index (WOSI), Disability of Arm Shoulder and Hand (DASH), and SSV (Simple Shoulder Value) assessments. RESULTS: Recurrance resulted revision surgery in 1 shoulder in the B-L group and in 5 shoulders in the B group (P = .08). Redislocation or subluxation after the index operation occurred in 13 of 97 B-L shoulders and in 25 of 87 of B shoulders (after excluding 1 patient with arthroplasty because of arthropathy, P = .017). Of the 96 Bristow shoulders, 94 patients were very satisfied/satisfied compared with 71 of 80 in the B series (P = .01). Mean WOSI score was 88 for B-L shoulders and 79 for B shoulders (P = .002). B-L shoulders also scored better on the DASH (P = .002) and SSV (P = .007). Patients had 11° loss of subjectively measured outward rotation with the arm at the side after B-L repair compared with 19° after Bankart (P = .012). The original Bankart, with tunnels through the glenoid rim, had less redislocation(s) or subluxation(s) than shoulders done with anchors (P = .048). CONCLUSIONS: Results were better after the Bristow-Latarjet repair than after Bankart repairs done with anchors with respect to postoperative stability and subjective evaluation. Shoulders with original Bankart repair also seemed to be more stable than shoulders repaired with anchors.

Epidemiology of fractures in children and adolescents.

BACKGROUND AND PURPOSE: Fractures are most common in youth and in the elderly, with differences in incidence over time and between regions. We present the fracture pattern in a population of youths

Mental status and surgical methods in patients with femoral neck fracture.

BACKGROUND: About one third of hip-fractured patients have dementia and thus may have difficulties adhering to postoperative instructions. Hip replacement is the most common treatment when a femoral neck fracture is displaced in healthy older people, whereas for those with dementia and other severe comorbidities, internal fixation (IF) is generally recommended. PURPOSE: To evaluate complications, functional outcome, and mortality for both surgical methods, IF and hemiarthroplasty (HAP), in older patients suffering from femoral neck fracture with or without dementia. SAMPLE: One hundred eighty patients, aged 70 years or older, who were operated on using IF (n = 69) in undisplaced femoral neck fracture and HAP (n = 111) if the fractures were displaced. DATA COLLECTION: Mental state was assessed using the Mini-Mental State Examination and Organic Brain Syndrome scale, and dementia and delirium were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Outcomes of mortality, complications, functional ability, and quality of life were measured. FINDINGS: There was no difference in complications or mortality at 4 months and 1 year for the IF or HAP groups. Patients with and without dementia, operated on with HAP, had a better functional outcome after 1 year than those operated on with IF. The result of this study indicates that dementia per se is not a reason for disqualifying those patients from the most appropriate surgical method.