[Spinal infection with spinal cord/cauda equina affection requires emergency handling]. / Spinal infektion med ryggmärgs­påverkan kräver snabba åtgärder - Genomgång av Ivo-anmälningar visar att fördröjd handläggning kan ge allvarliga restsymtom.

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.

[Missed diagnosis of Achilles tendon ruptures most common in elderly patients]. / Missad diagnos av hälseneruptur vanligast hos äldre patienter.

We audited forty-six patients with a rupture of the Achilles tendon notified to the Swedish regulatory authority (the Health and Social Care Inspectorate) due to suspicion of malpractice. The patients' history and clinical presentation differed from those with a more classical acute rupture. The diagnostic errors were often found in patients older than 60 years, they were just as common in women as in men and the symptoms often had a subacute start. In most patients, the diagnostic errors were due to an incomplete clinical examination. More than one fourth of the patients were on medication with statins or quinolones.

[Systematic analysis of diagnostic errors in patients with myocardial infarction handled by the Swedish Health and Social Care Inspectorate​]. / Missad hjärtinfarkt var ofta relaterad till atypisk anamnes - Systematisk genomgång av bakomliggande orsaker till anmälda fall av felaktig diagnostik vid akut hjärtinfarkt.

Systematic analysis of diagnostic errors in patients with myocardial infarction handled by the Swedish Health and Social Care Inspectorate​ Diagnostic errors in 51 patients with myocardial infarction handled by the Swedish Health and Social Care Inspectorate​ were analyzed. In more than half of the cases, the diagnostic errors occurred in health-care outside of hospitals. Diagnostic errors were more common when patients presented atypical symptoms, but atypical symptoms were equally common in male and female patients. Insufficient initial investigation, including lack of ECG registration, preceded a majority of the diagnostic errors. Wider indications for ECG and measurement of troponins in combination with increased awareness of atypical symptoms could possibly be remedies.

[Failing primary clinical investigation is common in missed hip fractures]. / Bristande initial handläggning vanligast vid missad höftfraktur - Fel vid anamnes, status eller röntgen orsakar de flesta fall, enligt retrospektiv kohortstudie.

Failing primary clinical investigation is common in missed hip fractures Diagnostic errors in 43 patients with hip fracture handled by the Swedish Health and Social Care Inspectorate were analyzed. Diagnostic errors were most likely a consequence of insufficient initial history, examination and/or radiologic examination. The most common isolated cause was delayed examination by a physician outside of a hospital setting. A substantial number of diagnostic errors were related to the radiological examination itself. Atypical symptoms were a minor cause of diagnostic errors. Since mortality in hip fracture is dependent on early surgery, preferably performed within 24 hours, diagnostic delay could prove disastrous to the patient.

[Diagnostic imaging no answer in the diagnosis of appendicitis]. / Bilddiagnostik inget facit vid diagnos av appendicit - Större acceptans i sjukvård än hos lekmän för att diagnosen kan vara svår.

Diagnostic errors in 49 patients with appendicitis handled by the Swedish Health and Social Care Inspectorate were analyzed. Diagnostic errors were more common in young or old patients, and among patients with atypical symptoms. Adjunct diagnostic tools, such as computerized tomography and/or ultrasound examination, also have limitations as regards diagnostic precision, and should therefore not be seen as golden standard. Increased individual knowledge, and not systems factors or safety culture, appears to be a suitable remedy against diagnostic errors.

[Lumbar spine radiography ­ unreliable diagnostic accuracy and negligible value for the patients]. / Ländryggsröntgen ger falsk säkerhet och ringa nytta för patienten - MRT och DT ger bättre och billigare resultat.

Lumbar spine radiography - unreliable diagnostic accuracy and negligible value for the patients In 2016 140 000 lumbar spine radiographies were performed in Sweden (14 000 per million inhabitants) to a cost of about 85 million SEK (≈8.5 million Euro) and a negligible value for the patients with low back pain. In the work-up of low back pain, when imaging is indicated, lumbar spine radiography should be replaced by limited magnetic resonance imaging including a whole lower body coronal STIR sequence or computed tomography with radiation dose adapted to indication and patient age. Indication for imaging should be restricted to 1) low back pain with more than 3-4 weeks duration in combination with at least one ¼red flag«, 2) radicular pain without improvement on conservative treatment, or 3) low back pain with more than 8 weeks duration in combination with ¼yellow flags«.

Knee rotation in healthy individuals related to age and gender.

An external device ("the Rottometer") was especially designed to measure passive knee rotation in vivo. The device had earlier been evaluated with respect to it's validity and reliability. In the present study, we evaluated knee rotation in knee-healthy individuals and studied possible age and gender related differences. Measurements of total internal-external rotation were made at 90°, 60°, and 30° of flexion using 6 and 9 N m torques, as well as the examiner's apprehension of end-feel as displacing forces. The study group constituted of 120 healthy subjects (60 females and 60 males) with no prior or present knee disorders. The sample was divided into four age groups (15-30, 31-45, 46-60, and >60 years). The results showed no differences in knee rotation between the right and left knees or between the different flexion angles. The females showed 10-20% (p < 0.01) larger knee rotation than the males at all the three flexion angles and at all the three applied torques in all age-matched groups. In all age groups in both genders, the internal rotation accounted for 40-44% and the external for 56-60% of the total internal-external knee rotation.

The influence of posterior-inferior tibial slope in ACL injury.

PURPOSE: To explore the effect of different posterior-inferior tibial slope (PITS) angles on ACL injury at non-contact sports, knee laxity and the need for ACL reconstruction. METHODS: One hundred patients with an acute, arthroscopically verified total ACL rupture were followed prospectively with the intention of treating the injury without reconstruction. Knee laxity was assessed with the Lachman and pivot shift tests with the patients under general anesthesia within 10 days of injury. After 15 years, 22 patients of 94 available for follow-up had undergone reconstruction a mean of 4 years after injury. Reconstruction was performed in case of repeated giving-way episodes (n = 16) or meniscus lesions suitable for fixation (n = 6). Knee radiographs were available from 82 patients. Two independent readers determined the PITS angle. RESULTS: Patients injured in contact sports had a greater mean PITS angle than those injured in non-contact sports (10.5° and 9.3°, respectively, P = 0.03). The mean PITS angle was 10.1 (SD = 2.3) for non-reconstructed knees and 9.1 (SD = 3.0) for reconstructed knees (P = NS). Eight of 17 reconstructed knees showed a PITS angle of less than 7.6° (P = 0.006), and the odds ratio of need for reconstruction was 3.9 (CI 1.26-12.3, P = 0.02). No significant difference in PITS angle was found between patients with low- and high-grade instability. CONCLUSION: The main finding of the study was that reconstructed knees were overrepresented in knees with extremely low PITS angles. Additionally, patients injured in contact sports had higher PITS angles than those injured in non-contact sports, and PITS angle did not influence knee laxity.

Measurements of knee rotation-reliability of an external device in vivo.

BACKGROUND: Knee rotation plays an important part in knee kinematics during weight-bearing activities. An external device for measuring knee rotation (the Rottometer) has previously been evaluated for validity by simultaneous measurements of skeletal movements with Roentgen Stereometric Analysis (RSA). The aim of this study was to investigate the reliability of the device. METHOD: The within-day and test-retest reliability as well as intertester reliability of the device in vivo was calculated. Torques of 3, 6 and 9 Nm and the examiner's apprehension of end-feel were used at 90°, 60° and 30° of knee flexion. Intraclass Correlation Coefficient 2,1 (ICC 2,1), 95% confidence interval (CI) of ICC and 95% CI between test trials and examiners were used as statistical tests. RESULT: ICC2,1 ranged from 0.50 to 0.94 at all three flexion angles at 6 and 9 Nm as well as end-feel, and from 0.22 to 0.75 at 3 Nm applied torque. CONCLUSION: The Rottometer was a reliable measurement instrument concerning knee rotation at the three different flexion angles (90°, 60° and 30°) with 6 and 9 Nm applied torques as well as the examiner's apprehension of end-feel. Three Nm was not a reliable torque. The most reliable measurements were made at 9 Nm applied torque.

Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation.

BACKGROUND: The association of early knee joint laxity with the need for later reconstruction of the anterior cruciate ligament has not been extensively studied. HYPOTHESIS: The grade of knee laxity can be used as an early predictor of the need for later reconstruction. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: One hundred consecutive patients with an acute arthroscopically verified total anterior cruciate ligament rupture were followed prospectively for 15 years. Lachman and pivot-shift tests were performed with the patient under general anesthesia before arthroscopy. After 3 months, the tests were repeated in an ordinary clinical setting. All patients underwent rehabilitation as the first choice of treatment. Anterior cruciate ligament reconstruction was performed only in cases of significant reinjuries (n = 16) or reparable meniscal lesions (n = 6) at a mean of 4 years after injury (range, 4 months-11 years). After 15 years, 94 patients were available for follow-up. RESULTS: Of the later reconstructed patients (n = 18), 82% had a high-grade Lachman test under anesthesia compared with 63% of the nonreconstructed patients (n = 45; P = .048). At 3 months, 44% of the nonreconstructed patients (n = 32) had a high-grade Lachman test compared with 82% of the reconstructed patients (n = 18; P = .007). Twenty-five patients displayed a normal pivot-shift test at 3 months, of whom 1 underwent later reconstruction (P = .009). A high-grade pivot-shift test at 3 months was associated with an 11.4 relative risk for reconstruction. CONCLUSION: A positive pivot-shift test at 3 months after injury in an awake patient is the strongest predictor for the future need for reconstruction. Furthermore, a normal pivot-shift test at 3 months indicates a low risk for reconstruction and is characteristic for copers.

Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study.

BACKGROUND: The occurrence of osteoarthritis (OA), associated meniscal injuries, meniscectomy, and patient-related measures for patients treated nonoperatively after anterior cruciate ligament (ACL) injuries have not been well described in the literature in terms of natural history. HYPOTHESIS: Patients with ACL injury can achieve a low occurrence of tibiofemoral OA and good knee function when treated without ACL reconstruction. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: One hundred consecutive patients with an acute, complete ACL injury were observed for 15 years. All patients were primarily treated with activity modification and without ACL reconstruction. To achieve improved functional stability, supervised physical therapy was initiated early after injury. The patients were examined using anteroposterior weightbearing radiography. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms and knee function. RESULTS: Seventy-nine patients consented to radiographic examination and 93 completed the KOOS questionnaire. Thirteen patients (16%), all of whom were among the 35 patients whose knees were meniscectomized, developed radiographic tibiofemoral OA. In contrast, none of the remaining nonmeniscectomized and radiographed knees developed OA (n = 44) (P < .0001). Sixty-three patients (68%) had an asymptomatic knee. Twenty-two patients (23%) had undergone ACL reconstruction with a mean time of 4 years after injury. CONCLUSION: The study had a favorable long-term outcome regarding incidence of radiographic knee OA, knee function and symptoms, and need for ACL reconstruction. Although risk factors for posttraumatic OA are multifactorial, the primary risk factor that stood out in this study was if a meniscectomy had been performed. Early activity modification and neuromuscular knee rehabilitation might also have been related to the low prevalence of radiographic knee OA. In patients with ACL injury willing to moderate activity level to avoid reinjury, initial treatment without ACL reconstruction should be considered.