Basicervical femoral neck fractures: an observational study derived from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR). METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality. RESULTS: The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF. CONCLUSION: Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.

Epidemiology, Treatment, and Mortality of 3,983 Scapula Fractures from the Swedish Fracture Register.

BACKGROUND: Scapula fractures are relatively uncommon, accounting for <1% of all fractures and approximately 3-5% of shoulder girdle fractures. This study comprehensively describes the epidemiology, fracture classification, treatment, and mortality associated with scapula fractures within a large adult Swedish population. METHODS: This observational study included all patients ≥18 years old at the time of injury with a scapula fracture (ICD S42.1) registered in the Swedish Fracture Register between March 2011 and June 2020. Variables studied were age, sex, and injury mechanism, including energy level, fracture classification, associated fractures, treatment, and mortality. RESULTS: We included 3,930 patients (mean age 58 years, SD 18, 64% men) with 3,973 scapula fractures. Some 22% of the fractures were caused by high-energy trauma and 21% had at least one associated fracture. High energy-injuries were most common in glenoid neck (44%) and scapular body (35%) fractures. However, same-level falls were the most common cause of glenoid rim (62%) and intra-articular glenoid (55%) fractures. Clavicle fractures (9%) and proximal humerus fractures (5%) were the most commonly associated fractures. The most common fracture types were the glenoid rim (n=1,289, 32%) and scapular body (n=1,098, 28%) fractures. Nonoperative treatment was performed in 81% of patients. Glenoid rim and intra-articular glenoid fractures were treated operatively in over 30% of cases. The mortality rate for the whole cohort was 4% at 1 year. CONCLUSIONS: Scapula fractures are predominately sustained by men. High energetic injuries and associated fractures are present in one in five patients. Nonoperative treatment is chosen in four of five patients, but for some fracture types one in three undergo surgery.

Reliability of thoracolumbar burst fracture classification in the Swedish Fracture Register.

BACKGROUND: The Swedish Fracture Register (SFR) is a national quality register for all types of fractures in Sweden. Spine fractures have been included since 2015 and are classified using a modified AOSpine classification. The aim of this study was to determine the accuracy of the classification of thoracolumbar burst fractures in the SFR. METHODS: Assessments of medical images were conducted in 277 consecutive patients with a thoracolumbar burst fracture (T10-L3) identified in the SFR. Two independent reviewers classified the fractures according to the AOSpine classification, with a third reviewer resolving disagreement. The combined results of the reviewers were considered the gold standard. The intra- and inter-rater reliability of the reviewers was determined with Cohen's kappa and percent agreement. The SFR classification was compared with the gold standard using positive predictive values (PPV), Cohen's kappa and percent agreement. RESULTS: The reliability between reviewers was  high (Cohen's kappa 0.70-0.97). The PPV for correctly classifying burst fractures in the SFR was high irrespective of physician experience (76-89%), treatment (82% non-operative, 95% operative) and hospital type (83% county, 95% university). The inter-rater reliability of B-type injuries and the overall SFR classification compared with the gold standard was low (Cohen's kappa 0.16 and 0.17 respectively). CONCLUSIONS: The SFR demonstrates a high PPV for accurately classifying burst fractures, regardless of physician experience, treatment and hospital type. However, the reliability of B-type injuries and overall classification in the SFR was found to be low. Future studies on burst fractures using SFR data where classification is important should include a review of medical images to verify the diagnosis.

Reoperation-free survival after hip screws or hip arthroplasty for undisplaced femoral neck fractures in the elderly.

Aims: Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately. Methods: We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately. Results: Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group. Conclusion: In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods.

Functional outcomes are restored a decade after a distal radius fracture: a prospective long-term follow-up study.

We performed an 11-13-year prospective follow-up of patients after a distal radial fracture (DRF) to investigate the association between fracture malunion, radiocarpal osteoarthritis and clinical outcome. In total, 292 patients responded to patient-reported outcome measures; of them, 242 underwent clinical examination. Clinical outcomes improved with time. A decade after fracture, median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 5, EuroQol Five-dimensions score was 1.0, and range of motion and grip strength were 96% of the contralateral side. Neither osteoarthritis (6%) nor pseudoarthrosis of the ulnar styloid (30%) affected the outcomes. Dorsal tilt, radial inclination, ulnar variance and intra-articular extension did not affect long-term clinical outcomes or the risk of osteoarthritis. Recovery after a DRF is an ongoing process that lasts years. A decade after the injury event, range of motion, grip strength and QuickDASH were recovered to population normal, regardless of radiological outcomes.Level of evidence: II.

The different strategies in treating displaced femoral neck fractures: mid-term surgical outcome in a register-based cohort of 1,283 patients aged 60-69 years.

BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively. PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event. RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register. CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.

Minimally Invasive Surgery for Thoracolumbar Spinal Fractures in Patients With Ankylosing Spondylitis.

BACKGROUND: Patients with ankylosing spondylitis (AS) are prone to spinal fractures even after low-energy trauma. Posterior fusion through open surgery has been the standard procedure for spinal fractures in patients with AS. Minimally invasive surgery (MIS) has been proposed as an alternative treatment option. There are few literature reports regarding patients with AS being treated for spinal fractures with MIS. This study aims to present the clinical outcome of a series of patients with AS treated with MIS for spinal fractures. METHODS: We included a consecutive series of patients with AS who underwent MIS for thoracolumbar fractures between 2014 and 2021. The median follow-up was 38 (12-75) months. Medical records and radiographs were reviewed, and data on surgery, reoperations, complications, fracture healing, and mortality were recorded. RESULTS: Forty-three patients (39 [91%] men) were included with a median (range) age of 73 (38-89) years. All patients underwent image-guided MIS with screws and rods. Three patients underwent reoperations, all due to wound infections. One patient (2%) died within 30 days and 7 (16%) died within the first year after surgery. Most patients with a radiographic follow-up of 12 months or more (29/30) healed with a bony fusion on computed tomography (97%). CONCLUSION: Patients with AS and a spinal fracture are at risk of reoperation and have significant mortality during the first year. MIS provides adequate surgical stability for fracture healing with an acceptable number of complications and is an adequate choice in treating AS-related spinal fractures.

Outcome following soft tissue coverage with a medial gastrocnemius flap of an exposed or infected total knee arthroplasty.

BACKGROUND: Soft tissue defects or periprosthetic infections after total knee arthroplasty (TKA) are severe complications that may lead to loss of the arthroplasty or the limb. Reconstructions with medial gastrocnemius flaps (MGF) are occasionally used to provide soft tissue coverage around the knee. AIMS: The study aimed to establish the rate of implant survivorship after MGF reconstruction for soft tissue coverage in the treatment of exposed or infected TKA and to establish functional outcome. METHODS: A retrospective analysis was performed on all patients who received soft tissue coverage with an MGF of an exposed or infected TKA between 2000 and 2017 at the Department of Hand and Plastic Surgery at Umeå University Hospital. The outcomes were implant survivorship and patient-reported outcome measures (PROMs) using the five-level EQ-5D version and The Knee Injury and Osteoarthritis Outcome Score. RESULTS: Forty-seven patients (mean age = 67 years, 30 women) were included. The mean time between flap coverage and follow-up was 6.7 (±3.4) years. Implant survivorship was observed in 28 of 47 (59.6%) patients at follow-up. Flap failure was rare, with only 3 of 47 (6.4%) cases. Of the 20 patients who answered the PROMs, 10 of 20 experienced moderate to severe pain or discomfort. CONCLUSIONS: Due to unfavorable underlying conditions, MGF reconstruction after TKA is often associated with a compromised functional outcome. Because donor site morbidity is limited and flap failure is unusual, the procedure can be considered prophylactically in a small subset of patients with risk factors to prevent soft tissue defects and periprosthetic joint infection.

Association Between Radiographic and Clinical Outcomes Following Distal Radial Fractures: A Prospective Cohort Study with 1-Year Follow-up in 366 Patients.

BACKGROUND: Several studies of distal radial fractures have investigated final displacement and its association with clinical outcomes. There is still no consensus on the importance of radiographic outcomes, and published studies have not used the same criteria for acceptable alignment. Previous reports have involved the use of linear or dichotomized analyses. METHODS: The present study included 438 patients who were managed with either reduction and cast immobilization or surgery for the treatment of distal radial fractures. Radiographic outcomes were determined on the basis of radiographs that were made 3 months after the injury. Clinical outcome was determined on the basis of the QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) score, range of motion, and grip strength at 1 year after the injury. Nonlinear relations were analyzed with cubic splines. RESULTS: Three hundred and sixty-six patients (84%) had both radiographic and clinical follow-up. Seventy patients were lost to follow-up. The mean age was 57 years (range, 18 to 75 years), and 79% of the patients were female. Dorsal tilt was the radiographic parameter that was most strongly associated with the QuickDASH score, grip strength, and range of motion. We found nonlinear relations. Clinical outcomes were found to worsen with increasing dorsal tilt, with the cutoff value being approximately 5°. CONCLUSIONS: We found that clinical outcomes following distal radial fractures have a nonlinear relationship with dorsal tilt, with worse outcomes being associated with increasing dorsal tilt. The decline in clinical outcome starts at 5°, but there is unlikely to be a noticeable difference in capability as measured with the QuickDASH until 20° of dorsal tilt (based on the minimum clinically important difference) in a population up to 75 years old. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Age, sex, primary tumor type and site are associated with mortality after pathological fractures: an observational study of 1453 patients from the Swedish Fracture Register.

BACKGROUND: Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient's quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures. METHODS: All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected. RESULTS: A total of 1453 patients with pathological fractures were included (48% women, median age 73, range 18-100 years). Unknown primary tumors were the most common primary site (n = 308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54-102), and multiple myeloma had the longest median survival of 432 days (range 232-629). The site at the lower extremity had the shortest (187 days, range 162-212), and the spine had the longest survival (386 days, range 211-561). Age, sex, primary type and site of the pathological fractures were all associated with mortality. INTERPRETATION: Age, sex, primary tumor type and site of pathological fractures were associated with survival. Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival.

Association of depressive disorders and dementia with mortality among older people with hip fracture.

BACKGROUND: Hip fracture (HF) is a significant cause of mortality among older people. Almost half of the patients with HF have dementia, which increases the mortality risk further. Cognitive impairment is associated with depressive disorders (DDs) and both dementia and DDs are independent risk factors for poor outcome after HF. However, most studies that evaluate mortality risk after HF separate these conditions. AIMS: To investigate whether dementia with depressive disorders (DDwD) affects the mortality risk at 12, 24, and 36 months after HF among older people. METHODS: Patients with acute HF (n = 404) were included in this retrospective analysis of two randomized controlled trials performed in orthopedic and geriatric departments. Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive function was assessed using the Mini-Mental State Examination. A consultant geriatrician made final depressive disorder and dementia diagnoses using the Diagnostic and Statistical Manual of Mental Disorders criteria, with support from assessments and medical records. The 12-, 24- and 36-month mortality after HF was analyzed using logistic regression models adjusted for covariates. RESULTS: In analyses adjusted for age, sex, comorbidity, pre-fracture walking ability, and fracture type, patients with DDwD had increased mortality risks at 12 [odds ratio (OR) 4.67, 95% confidence interval (CI) 1.75-12.51], 24 (OR 3.61, 95% CI 1.71-7.60), and 36 (OR 4.53, 95% CI 2.24-9.14) months. Similar results were obtained for patients with dementia, but not depressive disorders, alone. CONCLUSION: DDwD is an important risk factor for increased mortality at 12, 24, and 36 months after HF among older people. Routinely assessments after HF for cognitive- and depressive disorders could identify patients at risk for increased mortality, and enable early interventions. TRIAL REGISTRATION: RCT2: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN15738119.

Inter-departmental variation in surgical treatment of proximal femoral fractures: A nationwide observational cohort study.

BACKGROUND AND PURPOSE: Hip fractures should be treated based on the best available evidence and cost-effectively to optimize the outcome for this large group of frail patients. This study examined nationwide variation in surgical methods used for hip fractures. METHODS: In this cohort study 46,243 patients ≥65 years with a trochanteric hip fracture (THF) or a femoral neck fracture (FNF) registered in the Swedish Fracture Register (SFR) between 1 January 2016 and 31 December 2020 were included. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification system. The choice of surgical methods was assessed for each fracture type to compare national variation. RESULTS: 21,312 THFs and 24,072 FNFs (67% women) with a mean age of 83 years (SD 8) were surgically treated. In the treatment of two-fragment THFs (AO/OTA A1) departments ranged from using 90% short intramedullary nails to 98% sliding hip screws. Treating displaced FNFs (AO/OTA B3), the proportion of hemiarthroplasty ranged from 9 to 90%, and internal fixation between 0.6 to 21%, depending on the department. INTERPRETATION: A mature national fracture register permits the monitoring of treatment provided and thus serves as an important aid in assessing compliance with guidelines. The large inter-departmental variation in the surgical management of hip fractures in Sweden appears unwarranted based on the current evidence, indicating a need for updated national guidelines. Further research will have to clarify the impact of this variation on mortality and re-operation rates.

Conversion to Arthroplasty After Internal Fixation of Nondisplaced Femoral Neck Fractures: Results from a Swedish Register Cohort of 5,428 Individuals 60 Years of Age or Older.

BACKGROUND: Although most nondisplaced or minimally displaced femoral neck fractures are routinely treated with internal fixation, high rates of secondary surgical procedures are common, especially in the elderly population. Primary arthroplasty in elderly patients has been proposed as an alternative treatment to reduce the need for a secondary surgical procedure. The objective of this study was to describe the rate of conversion to arthroplasty within 5 years after internal fixation of nondisplaced femoral neck fractures in patients ≥60 years of age. METHODS: In this observational cohort study of prospectively collected data from the Swedish Fracture Register (SFR) between 2012 and 2018, cross-matched with the Swedish Arthroplasty Register (SAR), 5,428 nondisplaced femoral neck fractures in patients ≥60 years of age were included. Competing risk analysis was used to estimate conversion rates to arthroplasty and mortality in various age groups at 1, 2, and 5 years. RESULTS: The cumulative incidence function (CIF) for conversion to arthroplasty was 6.3% at 1 year, 8.1% at 2 years, and 10.1% at 5 years. The conversion rates within 2 years were 6.5% in 60 to 69-year-olds, 9.6% in 70 to 79-year-olds, and 7.8% in ≥80-year-olds. Women had a higher risk of conversion; the hazard ratio (HR) was 1.49 (95% confidence interval [CI], 1.19 to 1.87). The cumulative mortality was 21.3% (95% CI, 20.3% to 22.5%) at 1 year, 31.3% (95% CI, 30.0% to 32.6%) at 2 years, and 54.9% (95% CI, 53.1% to 56.7%) at 5 years. Mortality was higher in men at all time points, and the adjusted 1-year HR was 1.79 (95% CI, 1.61 to 2.00). CONCLUSIONS: One in 10 patients ≥60 years of age treated with internal fixation for a nondisplaced femoral neck fracture underwent conversion to arthroplasty within 5 years, and more than one-half of the conversions occurred within the first year. The risk of conversion was highest in women and in patients 70 to 79 years of age. These data warrant further studies in this frail patient group to identify subgroups of patients who would benefit from primary arthroplasty for nondisplaced femoral neck fractures. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Validity of the short musculoskeletal function assessment questionnaire in patients with a spine fracture.

PURPOSE: The aim of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in patients with a spine fracture. METHODS: Cross-sectional cohort of individuals that had sustained a spine fracture (C1-L5) one year earlier. Patients were asked to fill out SMFA, Oswestry Disability Index (ODI), EQ-5D-3L and EQ-VAS. Spearman's rank correlation coefficient (rho) was used to assess convergent validity for each patient-reported outcome measure (PROM). Bland-Altman plots were used to assess PROM agreement. RESULTS: 82 patients completed all questionnaires. The correlations between SMFA Dysfunction and Bother indices and ODI were 0.89 and 0.86, with EQ-5D-3L index 0.89 and 0.80, and with EQ-VAS 0.80 and 0.73, respectively. The correlation for separate categories of the SMFA dysfunction index (daily activities, emotional status, arm and hand function, mobility) ranged between 0.71-0.87 for ODI, 0.72-0.84 for EQ-5D-3L index, and 0.67-0.77 for EQ-VAS. A selection of the ten items of SMFA that had the highest correlations with ODI resulted in a correlation of 0.91. The agreements between SMFA indices and ODI in Bland-Altman plots were good with small differential biases and minimal proportional biases, but worse for SMFA and EQ-5D-3L index and EQ-VAS. CONCLUSION: The SMFA indices are highly correlated with ODI in patients with a spine fracture. The Dysfunction index and Bother index, or selected SMFA items, may be used to assess outcome in patients with spine fractures as an alternative to ODI.

Marginal secondary displacement in fractures of the distal radius at follow-up - an important predictor for late displacement and malunion.

Treatment recommendations in fractures of the distal radius are often based on the degree of displacement and functional demands. The fracture may be within an acceptable radiological range, but a marginal deterioration in alignment then occurs between the initial visit and follow-up. This may pose a risk for late displacement that may require further treatment. We secondarily analysed prospectively collected data and included 165 patients. We found that marginal secondary displacement (odds ratio (OR) 9.7), anterior comminution (OR 8.8), loss of anterior apposition (OR 6.8) and dorsal comminution (OR 2.6) were predictors of late displacement. Marginal secondary displacement is an important predictor of late displacement and malunion in fractures of the distal radius. Clinicians should not unequivocally accept general guidelines on alignment but also assess a deterioration in fracture alignment on radiographic follow-up and be aware of the potential need for surgery to avoid malunion in cases that show early secondary displacement, even when radiographic measures are within acceptable limits.Level of evidence: III.

Surgery for subacromial impingement syndrome and occupational biomechanical risk factors in a 16-year prospective study among male construction workers.

OBJECTIVE: The aim of this study was to assess the association between occupational biomechanical exposures and the occurrence of surgical treatment for subacromial impingement syndrome (SIS). METHODS: A cohort of 220 295 male constructions workers who participated in a national occupational health surveillance program (1971-1993) were examined prospectively over a 16-year follow-up period (2001-2016) for surgically treated SIS. Worker job title, smoking status, height, weight, and age were registered on health examination. Job titles were mapped to 21 occupational groups based on tasks and training. A job exposure matrix (JEM) was developed with exposure estimates for each occupational group. Surgical cases were determined through linkage with the Swedish national in- and outpatient registers. Poisson regression was used to assess the relative risks (RR) for each biomechanical exposure. RESULTS: The total incidence rate of surgically treated SIS over the 16-year observation period was 201.1 cases per 100 000 person-years. Increased risk was evident for workers exposed to upper-extremity loading (push/pull/lift) (RR 1.45-2.30), high hand grip force (RR 1.47-2.23), using handheld tools (RR 1.52-2.09), frequent work with hands above shoulders (RR 1.62-2.11), static work (RR 1.77-2.26), and hand-arm vibration (RR 1.78-2.13). There was an increased risk for SIS surgery for all occupational groups (construction trades) compared with white-collar workers (RR 1.56-2.61). CONCLUSIONS: Occupational upper-extremity load and posture exposures were associated with increased risk for surgical treatment of SIS, which underlines the need for reducing workplace exposures and early symptom detection in highly exposed occupational groups.

Patient-surgeon sex discordance impacts adverse events but does not affect patient-reported satisfaction after primary total hip arthroplasty: a regional register-based cohort study.

BACKGROUND AND PURPOSE: The sex of the surgeon has been proposed to be associated with a disparity in clinical outcomes after different surgical procedures. We investigated the association between surgeon-patient sex discordance and adverse events (AEs) and surgical AEs (SAEs) within 90 days after primary total hip arthroplasty (THA). We also investigated patient-reported satisfaction with surgical outcomes 1 year after the surgery. PATIENTS AND METHODS: We conducted a register-based cohort study including primary THAs performed due to osteoarthritis between 2008 and 2016 at 10 publicly managed hospitals in western Sweden. Hospital data was linked to the Swedish Arthroplasty Register and a regional patient register. Logistic regression models investigated discordant sex of patients and surgeons on AEs/SAEs and patient-reported satisfaction with the surgical outcome. RESULTS: 11,993 primary THAs were included in the study. The proportion of AEs for the concordant group was 7.3% and for the discordant group 6.1%. For SAEs, the proportion was 5.0% for the concordant group and 4.3% for the discordant group. After adjustment the discordant group still had a lower likelihood of an AE or SAE than the concordant group: adjusted odds ratio (aOR) for AE (0.82, 95%CI 0.71-0.95) and for SAE (0.86, CI 0.72-0.99). No association was detected between patient-reported satisfaction and sex discordance. CONCLUSION: Sex discordance between surgeons and patients is linked to a decreased risk of an AE but not a lower level of patient-reported satisfaction with the surgical outcome.

Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial.

BACKGROUND AND PURPOSE: Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF. STUDY DESIGN: The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.

Epidemiology, classification, treatment and mortality of Talus fractures: An observational study of 1794 talus fractures from the Swedish Fracture Register.

BACKGROUND: Epidemiological data on talus fractures from large nationwide and multicenter studies are rare. This study aims to describe the epidemiology, fracture classification and treatment regimens of talus fractures in a large adult Swedish population. METHODS: This observational study is based on data from the Swedish Fracture Register (SFR) including talar fractures in patients ≥18 with a sustained fracture between 2012 and 2021. Epidemiological data on sex, age, injury date, injury mechanism and type (high or low energy trauma), fracture classification (side, type), initial treatment and mortality were analysed. RESULTS: We included 1794 talus fractures (1757 patients, 60 % men). Mean age was 40.3 years (range 18-96), and a biphasic age distribution was seen in women. High-energy trauma caused 33 % of all talus fractures. Of all talus fractures, 817 (45.5 %) were classified as AO/OTA type A fractures (avulsion), 370 (20.6 %) as type B (neck) and 435 (24.2 %) as type C (body). The remaining 172 (9.6 %) talus fractures were not classified/unclassifiable. Men were in the majority in all fracture groups except A1. For type A1-3, B1 and C1-2 fractures, most patients were treated non-operatively; in B2-3 and C3 fractures most patients received operative management. Fracture fixation with screws was the dominating surgical treatment. The overall 30-day mortality was 0.2 %. CONCLUSION: Talus fractures are most commonly encountered in young and middle-aged men. In contrast to men, a biphasic age distribution was observed in women. Approximately half of the talus fractures are avulsions. Operative treatment, mostly screw fixation, is performed in more complex fracture configurations (B2, B3 and C3 fractures). LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals.

BACKGROUND: The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. METHODS: In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. RESULTS: We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. CONCLUSIONS: Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.