Epidemiology and mortality of pelvic and femur fractures-a nationwide register study of 417,840 fractures in Sweden across 16 years: diverging trends for potentially lethal fractures.

Background and purpose - Fractures of the pelvis and femur are serious and potentially lethal injuries affecting primarily older, but also younger individuals. Long-term trends on incidence rates and mortality might diverge for these fractures, and few studies compare trends within a complete adult population. We investigated and compared incidence and mortality rates of pelvic, hip, femur shaft, and distal femur fractures in the Swedish adult population.Patients and methods - We analyzed data on all adult patients ≥ 18 years in Sweden with a pelvic, hip, femur shaft, or distal femur fracture, through the Swedish National Patient Register. The studied variables were fracture type, age, sex, and 1-year mortality.Results - While incidence rates for hip fracture decreased by 18% (from 280 to 229 per 105 person-years) from 2001 to 2016, incidence rates for pelvic fracture increased by 25% (from 64 to 80 per 105 person-years). Incidence rates for femur shaft and distal femur fracture remained stable at rates of 15 and 13 per 105 person-years respectively. 1-year mortality after hip fracture was 25%, i.e., higher than for pelvic, femur shaft, and distal femur fracture where mortality rates were 20-21%. Females had an almost 30% lower risk of death within 1 year after hip fracture compared with males.Interpretation - Trends on fracture incidence for pelvic and femur fractures diverged considerably in Sweden between 2001 and 2016. While incidence rates for femur fractures (hip, femur shaft, and distal femur) decreased or remained constant during the studied years, pelvic fracture incidence increased. Mortality rates were different between the fractures, with the highest mortality among patients with hip fracture.

Income change after cruciate ligament injury - A population-based study.

OBJECTIVES: To investigate the association between choice of treatment and patients' income after cruciate ligament (CL) injury and assess the effect of different covariates such as sex, age, comorbidities and type of work. METHODS: This entire-population cohort study in Sweden included working patients with a diagnosed CL injury between 2002 and 2005, identified in The National Swedish Patient Register (n = 13,662). The exposure was the treatment choice (operative or non-operative treatment). The main outcome measure was average yearly income five years after CL diagnosis, adjusted for the following covariates: sex, age, comorbidities, type of work, region, calendar year, education and income. RESULTS: Relative to non-operative treatment, operative treatment was associated with greater average yearly incomes (nine to 15%) after injury among patients between 20 and 50 years, patients with partial university education, patients living in large cities and patients with one comorbidity, despite no overall significant association in the national cohort. Delayed operative treatment (>1 year) had no significant association with income change, whereas early operative treatment (<1 year) was associated with higher average yearly incomes (11 to 16%) among females, patients between 20 and 50 years, patients living in large cities and patients with one comorbidity. CONCLUSIONS: In a broad sense, treatment choice was not associated with changes in income five years after CL injuries among patients in the workforce, however earlier operative treatment was associated with higher average incomes among patients with ages between 20 and 50, females, living in large cities, with one comorbidity and with a high level of education.

The outcome of patients with cultured pathogens at time of nonunion surgery.

The purpose of this study is to evaluate incidence, preoperative laboratory markers, and outcomes of patients who positively cultured pathogens (PCP) at time of surgery for long bone fracture nonunion. Two-hundred and eighty-eight patients were enrolled in a trauma study on long bone nonunion. Two-hundred and sixteen of those 288 patients were cultured at the time of fracture nonunion surgery. Laboratory data were collected prior to intervention and infectious laboratory markers ordered on patients suspected for infection. Patients were followed for one year. Wound complications, antibiotic use, healing, function, and re-admission for further surgery were assessed. Cultures returned positive on 59 patients (representing 20.5% of the 288 patient cohort or 27.3% of the 216 patients cultured in the operative suite). More PCP's (47.5%; 28 of 59) developed wound complications, with greater mean antibiotic duration and more frequent returns to the OR averaging 1.3 procedures per patient. Twelve-month follow-up was obtained on 249 of the 288 (86.5%) and PCPs reported globally worse function. Patients who PCP at the time of operative management for long bone nonunion was a prognostic indicator of poorer long-term functional outcomes.

The Effect of Socioeconomic Status on the Choice of Treatment for Patients With Cruciate Ligament Injuries in the Knee: A Population-Based Cohort Study.

BACKGROUND: The socioeconomic status (SES) of patients has been widely recognized as playing an important role in many health-related conditions, including orthopaedic conditions, in which a higher SES has been associated with a higher utilization of more advanced medical treatments such as drugs, diagnostics, and surgery. However, the association between SES and cruciate ligament surgery has not been thoroughly investigated. PURPOSE: To evaluate the association between SES and choice of treatment in patients with a cruciate ligament injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All Swedish patients with a diagnosed cruciate ligament injury between 1987 and 2010 were identified from the Swedish National Patient Register (N = 98,349). The Longitudinal Integration Database for Health Insurance and Labor Market Studies (LISA) provided information on household income and highest achieved educational level, which were used as socioeconomic indices. The exposure was the SES of patients as determined by the household income and educational level, and the main outcome measure was treatment choice (surgical reconstruction vs nonoperative treatment). Poisson regression models estimated the association. RESULTS: A total of 52,566 patients were included in the study; of these, 20,660 (39%) were treated operatively. Patients in the highest quartile of household income had a significantly higher likelihood of undergoing surgery than those in the lowest quartile (relative risk [RR], 1.16; 95% CI, 1.11-1.20). Patients classified as highly educated had a significantly increased likelihood of being treated operatively compared with those with a low education (RR, 1.29; 95% CI, 1.19-1.39). CONCLUSION: This study provides a population-based validation that having a higher SES as determined by the household income and/or level of education increases the likelihood of undergoing operative treatment after a cruciate ligament injury. CLINICAL RELEVANCE: All Swedish citizens are entitled by law to the same quality of health care; therefore, unmotivated differences in treatment between different socioeconomic groups are to be seen as a challenge. It is important to evaluate the specific mechanisms by which the patient's SES influences the decision of whether to treat a cruciate ligament injury operatively.

Nature's wrath-The effect of weather on pain following orthopaedic trauma.

BACKGROUND: Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. METHODS: We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. RESULTS: Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. CONCLUSIONS: Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.

Failure of Anterior Cruciate Ligament Reconstruction.

The present review classifies and describes the multifactorial causes of anterior cruciate ligament (ACL) surgery failure, concentrating on preventing and resolving such situations. The article particularly focuses on those causes that require ACL revision due to recurrent instability, without neglecting those that affect function or produce persistent pain. Although primary ACL reconstruction has satisfactory outcome rates as high as 97%, it is important to identify the causes of failure, because satisfactory outcomes in revision surgery can drop to as much as 76%. It is often possible to identify a primary or secondary cause of ACL surgery failure; even the most meticulous planning can give rise to unexpected findings during the intervention. The adopted protocol should therefore be sufficiently flexible to adapt to the course of surgery. Preoperative patient counseling is essential. The surgeon should limit the patient's expectations for the outcome by explaining the complexity of this kind of procedure. With adequate preoperative planning, close attention to details and realistic patient expectations, ACL revision surgery may offer beneficial and satisfactory results for the patient.

Pectoralis major transosseous equivalent repair with knotless anchors: Technical note and literature review.

INTRODUCTION: Rupture of the pectoralis major (PM) tendon was initially described almost 2 centuries ago, but most of the reported injuries have occurred within the last 30 years. Options for repair have varied widely. The most common methods for repair depend on either transosseous sutures or suture anchors for fixation. Transosseous suture repair allows for docking the tendon into a trough at its anatomic insertion, but risks cortical breakage during suture passing. Our experience has confirmed the value and potential advantages of anchors for a secure fixation. AIMS: To describe a variation of repair using knotless suture anchors and a burred trough to dock the tendon into its anatomic insertion. CONCLUSION: We describe a technique of a transosseous equivalent PM repair technique. To our knowledge, this is the first paper describing such a repair technique for PM rupture.

Symptomatic atypical femoral fractures are related to underlying hip geometry.

The benefits of bisphosphonates are well documented, but prolonged use has been associated with atypical femur fractures. Radiographic markers for fracture predisposition could potentially aid in safer medication use. In this case-control designed study, we compared hip radiographic parameters and the demographic characteristics of chronic bisphosphonate users who sustained an atypical femoral fracture with a group of chronic bisphosphonate users who did not sustain an atypical femur fracture and also a group who sustained an intertrochanteric hip fracture. Radiographic parameters included were neck-shaft angle (NSA), hip-axis length (HAL) and center-edge angle (CE). Multivariate regression was used to evaluate the relationship between radiographic measures and femur fracture. Receiver-operating characteristic analysis determined cut-off points for neck-shaft angle and risk of atypical femur fracture. Ultimately, pre-fracture radiographs of 53 bisphosphonate users who developed atypical fracture were compared with 43 asymptomatic chronic bisphosphonate users and 64 intertrochanteric fracture patients. Duration of bisphosphonate use did not statistically differ between users sustaining atypical fracture and those without fracture (7.9 [±3.5] vs. 7.7 [±3.3] years, p=0.7). Bisphosphonate users who fractured had acute/varus pre-fracture neck-shaft angles (p<0.001), shorter hip-axis length (p<0.01), and narrower center-edge angles (p<0.01). Regression analysis revealed associations between neck-shaft angle (OR=0.89 [95% CI=0.81-0.97; p=0.01), center edge angle (OR=0.89 [95% CI=0.80-0.99]; p=0.03), and BMI (OR=1.15 [95% CI=1.02-1.31; p=0.03) with fracture development. ROC curve analysis (AUC=0.67 [95% CI=0.56-0.79]) determined that a cut-off point for neck-shaft angle <128.3° yielded 69% sensitivity and 63% specificity for development of atypical femoral fracture. Ultimately, an acute/varus angle of the femoral neck, high BMI, and narrow center-edge angle were associated with development of atypical femur fracture in long-term bisphosphonate users. Patients on long-term bisphosphonates should be regularly radiographically evaluated in order to assess for potential risk of atypical fracture.