An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation.

Background and purpose - Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods - 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results - The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25-0.91) and by 46% (HR =0.54, 95% CI: 0.35-0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation - With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.

[Patients in need for major lower extremity amputations are a challenge]. / Den amputationstruede patient er en udfordring for sundhedsvæsenet.

Major lower extremity amputations based on end-stage chronic leg ischaemia or diabetic ulcers with infection are relatively common orthopaedic procedures. Patients are usually evaluated for the possibility of lower extremity revascularisation. Those who are not fit for vascular surgery are transferred to an orthopaedic department for amputation. These patients are a big challenge as they are by definition multi-morbid individuals, who have to undergo major surgery. The high mortality rate in this population warrants new approaches, including optimised multidisciplinary regimes.

Locking plate osteosynthesis of clavicle fractures: complication and reoperation rates in one hundred and five consecutive cases.

PURPOSE: Locking plate osteosynthesis has become the preferred method for operative treatment of clavicle fractures. The method offers stable fixation, and would theoretically be associated with a low rate of fracture-related complications and reoperations. However, this remains to be explored in a large cohort, and our purpose was to assess the overall rates of complications and reoperations following locking plate osteosynthesis of mid-shaft clavicle fractures. METHODS: We identified all locking plate osteosynthesis of mid-shaft clavicle fractures operated upon in our department from January 2008 to November 2010 (n = 114). Nine patients did not attend the follow-up at our institution. The study group of 105 fractures (104 patients, 86 males) had a median age of 36 years (14-75 years). Follow-up ranged from 0.5 to 3.5 years. No patients were allowed to load the upper extremity for six weeks. By studying patient files and radiographic material, we assessed complications and reoperations. RESULTS: Overall, there were 31 cases (30 %) of plate removals for discomfort. There were five cases (5 %) of failure of osteosynthesis: two occurred early after approximately six weeks and three late after ten to 13 months postoperatively. CONCLUSION: The overall rate of failure of osteosynthesis is low (5 %). The burden of plate removals in approximately one third of patients should be included in the preoperative information.

Immediate weight-bearing after osteosynthesis of proximal tibial fractures may be allowed.

INTRODUCTION: Immediate weight-bearing following osteosynthesis of proximal tibial fractures is traditionally not allowed due to fear of articular fracture collapse. Anatomically shaped locking plates with sub-articular screws could improve stability and allow greater loading forces. The purpose of this study was to investigate if immediate weight-bearing can be allowed following locking plate osteosynthesis of proximal tibial fractures. MATERIAL AND METHODS: Locking plate osteosynthesis of partial articular proximal tibial fractures (Arbeitsgemeinschaft für Osteosynthesefragen type 41B) operated from November 2007 to September 2009 at Hvidovre Hospital were included retrospectively (n = 32). Complications, reoperations and radiographic outcome at 6-8 week of follow-up were assessed. Twenty patients were not allowed to bear weight the first 6-8 weeks, whereas twelve were allowed immediate postoperative weight-bearing. RESULTS: The use of bone allograft, the number of screws inserted and the application of postoperative articular mobilizing brace were comparable between the two groups (p = 0.08). Persisting depressions of the articular surface ranged from 0 to 5 mm postoperatively with no difference between the groups (p = 0.36). At 6-8 weeks postoperatively, no changes in radiographic configuration of the fracture site were observed in either group. CONCLUSION: This retrospective study suggests that immediate weight-bearing following locking plate osteosynthesis of partial articular proximal tibial fractures may be allowed. Future, larger prospective randomised studies are needed. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Clavicle fractures may be conservatively treated with acceptable results - a systematic review.

INTRODUCTION: The optimal treatment of acute, displaced midshaft clavicle fractures is controversial. Despite lack of compelling evidence towards superior results after primary surgery, it seems that more and more patients are treated surgically. The aim of this study was to investigate which treatment modality should be preferred in this population according to current literature. METHOD: Randomized trials and prospective cohort studies comparing different treatment modalities for acute, displaced midshaft clavicle fracture in adults, published in English from 1966 to August 2011 were sought via an electronic database search (MEDLINE). RESULTS: Five studies with a total of 365 patients were identified. All fractures were described as midshaft fractures with complete displacement of their bony parts. Overall, the functional outcome (measured with the Constant score) was better in the surgically treated groups than in the conservatively treated groups. Likewise, union rates were higher in the surgical groups than in the conservative groups. Overall, complication rates were close to 30% in the surgically treated groups compared with 47% in the conservatively treated groups. CONCLUSION: Surgical treatment of acute, displaced midshaft clavicle fractures with a plate yields a better functional outcome and lower mal- and nonunion rates than conservative treatment. However, the clinical relevance of the observed functional benefits are questionable as is the use of the shoulder outcome scores frequently employed to assess the functional outcome of clavicle fracture treatment. When operative treatment is preferred, the number needed to treat to avoid a nonunion is high.

Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do?

The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.

A new algorithm for hip fracture surgery. Reoperation rate reduced from 18 % to 12 % in 2,000 consecutive patients followed for 1 year.

BACKGROUND AND PURPOSE: Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results. METHODS: 2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were prospectively included. 1,000 of these patients were included after implementation of the algorithm. Demographic parameters, hospital treatment, and reoperations within the first postoperative year were assessed from patient records. RESULTS: 931 of 1,000 operative procedures were performed according to the algorithm, as compared to only 726 of 1,000 prior to its introduction (p < 0.001). After implementation of the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192 of 1,000 to 105 of 1,000 (p < 0.001). The rate of reoperations declined from 18% to 12% (p < 0.001 in a multiple Cox regression analysis), with a decline of 24% to 18% for intracapsular fractures and a decline of 13% to 7% for extracapsular fractures. The proportion of bed-days caused by reoperations was reduced from 24% of total hospitalization before the algorithm was introduced to 18% after it was introduced. INTERPRETATION: It is possible to implement an algorithm for treatment of all hip fracture patients in a large teaching hospital. In our case, the Hvidovre algorithm both raised the rate of supervision and reduced the rate of reoperations. The reduced reoperation rate saved many hospital bed-days.

[Promising conservative treatment using dynamic mobilisation after Achilles tendon rupture]. / Lovende resultater ved konservativ behandling med dynamisk mobilisering efter akillesseneruptur.

There is no consensus regarding the optimal treatment of acute Achilles tendon ruptures. This review of the literature on the subject shows a significantly higher rate of reruptures (RR) in the conservatively treated group compared to the surgically treated group when the foot is immobilised in the aftertreatment. Recent studies that used early dynamic mobilisation in the conservatively treated group did not show this difference in the RR rate. The latest literature on the subject indicates that non-operative treatment, followed by dynamic aftertreatment, results in the lowest complication rate and a good functional outcome.

Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year.

BACKGROUND AND PURPOSE: In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fractured lateral femoral walls, where it often led to lack of healing in a maximally telescoped position. We hypothesized that INs would be the superior implant in these specific circumstances. METHODS: We retrospectively examined 311 consecutive patients treated in our department between 2002 and 2008, with either an IN (n = 158) or an SHS (n = 153) mounted on a 4-hole side-plate, for an AO/OTA type 31A1-2 pertrochanteric fracture with a detached greater trochanter. The status of the lesser trochanter was assessed preoperatively and the integrity of the lateral femoral wall, fracture reduction, and position of the implants were assessed postoperatively. Reoperations due to technical failure were recorded for one year postoperatively. RESULTS: Multivariate logistic regression analysis showed that the groups were similar regarding demographic and biomechanical parameters. The lateral femoral wall was more frequently fractured during SHS implantation (42 patients) than in the IN group (9 patients) (p < 0.001). 6 (4%) of the 158 patients operated with IN had to be reoperated, as compared to 22 (14%) in the SHS group of 153 patients (p = 0.001). INTERPRETATION: IN had a lower reoperation rate than SHS in these pertrochanteric hip fractures with a detached greater trochanter. IN left more lateral femoral walls intact.

A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1 year.

BACKGROUND AND PURPOSE: Preoperative posterior tilt in undisplaced (Garden I-II) femoral neck fractures is thought to influence rates of reoperation. However, an exact method for its measurement has not yet been presented. We designed a new measurement for posterior tilt on preoperative lateral radiographs and investigated its association with later reoperation. PATIENTS AND METHODS: A consecutive series of 113 patients, > or = 60 years of age with undisplaced (Garden I-II) femoral neck fractures treated with two parallel implants, was assessed regarding patient characteristics, radiographs, and rate of reoperation within the first year. In a subgroup of 50 randomly selected patients, reliability tests for measurement of posterior tilt were performed. RESULTS: Intra- and interclass coefficients for the new measurement were > or = 0.94. 23% (26/113) of patients were reoperated and increased posterior tilt was an accurate predictor of failure (p = 0.002). 14/25 of posteriorly tilted fractures > or = 20 degrees were reoperated, as compared to 12/88 of fractures with less tilt (p < 0.001). In multiple logistic regression analysis including sex, age, ASA score, cognitive function, new mobility score, time from admission to operation, surgeon's expertise, postoperative reduction, and implant positioning, a preoperative posterior tilt of > or = 20 degrees was the only significant predictor of reoperation (p < 0.001). INTERPRETATION: The new measurement for posterior tilt appears to be reliable and able to predict reoperation in patients with undisplaced (Garden I-II) femoral neck fractures.

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery.

BACKGROUND: Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown. PATIENTS AND METHODS: A total of 120 elderly, cognitively intact hip fracture patients admitted from their own home were randomly assigned to receive transfusion at a hemoglobin threshold of 10.0 g per dL (liberal) versus 8.0 g per dL (restrictive) in the entire perioperative period. Patients were treated according to a well-defined multimodal rehabilitation program. Primary outcome was postoperative functional mobility measured with the cumulated ambulation score (CAS). RESULTS: Patients in the liberal group received transfusions more frequently than those in the restrictive group (44 patients vs. 22 patients; p < 0.01) and received more transfusions during hospitalization (median, 2 units [interquartile range, 1-2] vs. 1 [1-2]; p < 0.0001). There were no significant differences in postoperative rehabilitation scores (CAS: median, 9 [9-15] vs. 9 [9-13.5]; p = 0.46) or in length of stay (median, 18 days vs. 16 days, respectively; p = 0.46). There were fewer patients in the liberal transfusion group with cardiovascular complications (2% vs. 10%; p = 0.05) and a lower mortality (0% vs. 8%; p = 0.02). CONCLUSION: Although a liberal transfusion trigger did not result in increased ambulation scores, restrictive transfusion thresholds should be treated with caution in elderly high-risk hip fracture patients, until their safety has been proved in larger randomized studies.

Symptomatic heterotopic ossification after very severe traumatic brain injury in 114 patients: incidence and risk factors.

The incidence of heterotopic ossification (HO) among patients with traumatic brain injury (TBI) varies in the literature from 11 to 73.3%. The aim of this study was to determine the incidence of HO among patients with very severe TBI treated in a new established intensive rehabilitation Brain Injury Unit and to list some of the risk-predicting features. The study comprised an approximately complete, consecutive series of 114 adult patients from a well-defined geographical area, and with a posttraumatic amnesia period of at least 28 days, i.e. very severe TBI. Demographic and functional data as well as data about trauma severity and hospital stay of these patients have been registered prospectively in a database (Danish National Head Injury database) at the Brain Injury Unit where the sub acute rehabilitation took place. The present study was based retrospectively on this database, combined with X-rays obtained for symptoms of HO and/or as fracture control. Clinically significant HO was found in 7.9% of the patients. Logistic regression showed an independent significant positive correlation between HO, the female gender and a high Injury Severity Score. The low incidence of HO might be explained by the application of early mobilisation and physiotherapy of the patients. The higher incidence of HO among women speaks for humoural and hormone factors initiating bone formation outside the bones.

Influence of surgeon's experience and supervision on re-operation rate after hip fracture surgery.

OBJECTIVE: To investigate the influence of the performing surgeon's experience and degree of supervision on re-operation rate among patients admitted with a proximal femoral fracture (PFF). METHODS: Prospective study of 600 consecutive patients with proximal femoral fracture in our multimodal rehabilitation programme, between 2002 and 2004. Re-operation rate was assessed 6 months postoperatively. Surgeons were grouped as unsupervised junior registrars versus experienced surgeons operating or supervising. Fractures were stratified as technically undemanding or demanding. RESULTS: Unsupervised junior registrars operated on 23% (137/600) of all and 15% (56/365) of technically demanding proximal femoral fractures. The latter had a higher re-operation rate within 6 months, compared with the rate when more experienced surgeons were present. In logistic regression analysis combining age, gender, American Society of Anaesthesiologists score, New Mobility Score, time to surgery and type of implant, surgery by unsupervised junior registrars was still a significant independent risk factor for re-operation in technically demanding proximal femoral fractures. CONCLUSION: Unsupervised junior registrars should not operate on technically demanding proximal femoral fractures.

Impact of surgical complications on length of stay after hip fracture surgery.

BACKGROUND: Rehabilitation after hip fracture may be lengthy, with bed-day consumption accounting for up to 85% of the total cost of admission to hospital. Data suggest that surgical complications requiring reoperation may lead to an excessively long in-patient stays. However, the overall impact of surgical complications has not been examined in detail. METHODS: All 600 consecutive patients included were admitted with primary hip fracture and received primary surgical intervention with multimodal rehabilitation. Surgical complications were audited and classified as being due to a patient fall, infection or suboptimal surgery, stratified into either requiring reoperation or not allowing mobilisation because of instability. RESULTS: Of the 600, 116 (19.3, 95% CI 16-22%) patients underwent reoperation or immobilisation; 27.1% of bed-day consumption resulted from surgical complications. The audit showed that 64 complications (55%) were due to suboptimal surgery, 18 (16%) to infection, 6 (5%) to falls and 28 (24%) to no obvious cause. CONCLUSION: Surgical complications secondary to primary hip fracture surgery account for 27.1% of total hospital bed consumption within 6 months. Approximately, 50% of these hospital days might be spared by optimal surgery.

[Surgical treatment of proximal femoral fracture]. / Operativ behandling af hoftenaere femurfrakturer.

In Denmark, 11,000 patients with proximal femoral fractures are admitted to hospital each year, using 2.2% of the national hospitalisation capacity. The patients are generally old and have a high degree of co-morbidities. In Denmark, the 30-day mortality rate is 10%, and on an international level, reoperation rates of 10-20% are reported. This article reports on current treatment stategies, classifications and surgical techniques and presents possible guidelines. The use of specialized centres and accelerated clinical programmes in Denmark is recommended.