Aim

Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate.

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months.

The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group.

In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly.

Cite this article: Bone Joint J 2015;97-B:1475–80.

The aim of this study was to investigate the epidemiology of fractures of the distal radius in the Swedish population and to review the methods used to treat them between 2005 and 2010.

The study population consisted of every patient in Sweden who was diagnosed with a fracture of the wrist between 1 January 2005 and 31 December 2010. There were 177 893 fractures of the distal radius. The incidence rate in the total population was 32 per 10 000 person-years. The mean age of the patients was 44 years (0 to 104). The proportion of fractures treated operatively increased from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation in the adult population increased 3.61 fold. The incidence rate for external fixation decreased by 67%. The change was greatest in the 50 years to 74 years age group.

In Sweden, there is an increasing tendency to operate on fractures of the distal radius. The previously reported increase in the use of plating is confirmed: it has increased more than threefold over a five-year period.

Cite this article: Bone Joint J 2014;96-B:963–9.

Introduction: Hemiarthroplasty (HA) and total hip replacement (THR) are standard surgical procedures in the treatment of elderly patients with displaced fractures of the femoral neck with a predictable outcome regarding hip function and health-related quality of life (HRQoL). However, dislocation of the prosthesis remains a significant problem in this patient cohort with a reported incidence of 2–16% after HA and 2–22% after THR. Even though a dislocation is a relatively common, severe, and expensive complication, there are no previous prospective studies reporting the HRQoL for patients suffering prosthetic dislocations.

Patients and Methods: During the year 2003, 2213 consecutive patients with an acute hip fracture admitted to any of the four major university hospitals in Stockholm County were included in a prospective cohort study. From that cohort, 319 consecutive patients with a displaced femoral neck fracture (Garden III and IV) treated with a primary HA or THR were included. Patients with severe cognitive dysfunction and/or dementia were not included. HRQoL was assessed with the EQ-5D. The EQ-5D index score during the last week before the fracture and at 4 and 12 months after surgery was calculated. All dislocations and associated reoperations were recorded. Patients were divided into three groups: no dislocation (0), only one dislocation (1), and those suffering recurrent dislocations (≥2) during the 12-month follow-up. We used a mixed linear model to perform a multivariable analysis of the influence of dislocations on HRQoL measured as the EQ-5D index score over time. Six independent factors were analyzed: dislocation, time, type of prosthesis (THR, cemented HA, and uncemented HA), ASA class, gender, and age.

Results: A prosthetic dislocation occurred in 21 of the 319 patients (6.6%). All first and second dislocations occurred before the 4-month follow-up. Patients suffering recurrent dislocations had a significantly lower EQ-5D index score compared to those without dislocations at both 4 and 12 months. Patients suffering only one dislocation had a temporary decrease in the EQ-5D index score at 4 months while their EQ-5D index score at 12 months was equal to that of patients without dislocations. The adjusted multivariable analysis indicated that dislocation, type of prosthesis and time were significantly related to the quality of life.

Discussion: In patients with fractures of the femoral neck treated with a primary hip arthroplasty recurrent dislocations of the prosthesis had a pronounced negative influence on the patients’ HRQoL, while in patients with only one dislocation, the HRQoL seems to recover during the first year after surgery.

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome.

Setting: Six major hospitals in Stockholm County.

Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome.

Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures.

Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon.

Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA).

Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively.

Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative.

Introduction: The treatment for the active and lucid elderly patient with a displaced femoral neck fracture is still controversial. Recent randomized controlled trials have shown that a primary total hip replacement (THR) is superior to internal fixation (IF) regarding the need for secondary surgery, hip function, and the health-related quality of life (HRQoL). Despite the good results with THR in this patient group, a vast majority of orthopaedic surgeons prefer hemiarthroplasty (HA) before THR. The aim of this study was to analyze the outcome regarding hip function and HRQoL after a displaced femoral neck fracture in a active and lucid elderly patient randomized to either a bipolar HA or THR.

Patients and Methods: 120 patients (101 females), mean age 81 (range 70 – 90), with an acute displaced femoral neck fracture (Garden III and IV) were randomized to bipolar HA or THR. Perioperative data, hip complications, general complications, hip function (Harris Hip Score, HHS) and HRQoL (EQ-5D) were assessed. The patients were summoned at 4 and 12 months.

Results: The duration of surgery was longer in the THR group, 102 versus 78 min, and the intraoperative blood loss was higher, 460 ml versus 320 ml. There were no differences between the groups regarding hip complications and general complications including mortality. There were no dislocations. Hip function (HHS score) was significantly better in the THR group at both follow-ups, p< 0.05 and < 0.001, respectively, with a trend towards an increasing difference with time. The HRQoL (EQ-5D index score) were in favor of the THR group although not statistically significant.

Discussion: The results of this study indicate that a THR gives better hip function compared to a bipolar HA already after one year without increasing the complication rate. There are good reasons to assume that this difference will increase with time. We recommend THR as the primary treatment for the active and lucid elderly patient with a displaced femoral neck fracture.

Introduction: Humeral shaft fractures account for 1–3% of all fractures. Little is known about additional epidemiological data on this specific fracture type. The aim of this study was to investigate the epidemiology of humeral shaft fractures in patients 16 years or older in Stockholm during the years 1998–99.

Patients and Methods: All patients 16 years or older with a humeral shaft fracture admitted to any of six major hospitals in the County of Stockholm during the two years 1998–99 were included in the study. A total of 401 fractures in 397 patients were found. Three hundred and sixty-one of the fractures were traumatic and were classified according to the Orthopaedic Trauma Association (OTA) classification system. The remaining 40 fractures were pathological (n=34) or peri-implant fractures (n=6). Open fractures were classified using the Gustilo classification system. Data regarding the injury mechanism, age, gender, side of the injury and occurrence of possible radial nerve injury were collected from the medical charts. The overall incidence and the age-specific incidence were calculated on the basis of data from Statistics Sweden.

Results: The incidence was 14.5 per 100 000 persons per year with a gradually increasing age-specific incidence from the fifth decade in both genders and reaching an incidence of almost 60 per 100 000 persons and year in the ninth decade. The majority of fractures were closed ones sustained after simple falls among elderly patients. The age distribution among females was characterised by a peak in the eighth decade while the age distribution among males was more even. Type A (simple) fractures were by far the most common and the majority of the fractures were located in the middle and proximal parts of the humeral shaft. The incidence of radial palsy was 8%. Fracture localisation in the middle and distal part of the shaft was associated with an increased risk for having radial nerve palsy. Only 2% of the fractures were open and 8% were pathological.

Discussion: These recent epidemiological data on humeral shaft fractures are representative of a society with a limited amount of high-energy trauma, including penetrating trauma, which probably reflects the situation in the majority of European countries. Our results can be used to facilitate the future treatment of patients with this particular fracture.

Background: Prophylaxis against thromboembolic complications has become routine after major trauma and major orthopaedic surgery. In contrast, it remains an issue for debate whether prophylaxis after minor surgery and immobilization is necessary, even though these treatments are well-known risk factors for deep vein thrombosis (DVT).

Objectives: The objective of this study was to evaluate the efficacy of Dalteparin (5,000 U given subcutaneously once daily for six weeks) during lower limb immobilization after surgical treatment of Achilles tendon rupture.

Methods: After surgery, 105 consecutive patients were randomized to a placebo-controlled double-blind study to evaluate the efficacy of given thromboprophylaxis. DVT screening using validated color duplex sonography was performed three weeks and six weeks after surgery, and all DVTs were confirmed with phlebography.

Results: Primary endpoint analysis was available for 91 patients. DVT was diagnosed in 16/47 patients (34%) in the Dalteparin group and in 16/44 patients (36%) in the placebo group. These figures are not significantly different (p=0.8). Proximal DVT was diagnosed in one patient (2%) in the Dalteparin group and in three patients (6%) in the placebo group (p=0.6). No pulmonary emboli or major bleeding occurred in either of the groups.

Conclusions: DVT is common after surgical treatment of Achilles tendon rupture and therefore effective thromboprophylaxis is desirable. Thromboprophylaxis with Dalteparin however, does not affect the incidence of DVT during the immobilization after Achilles tendon rupture surgery. Long-term effects of immobilization, such as the risk for post-thrombotic syndrome, need to be investigated further.

The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data, general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12 months.

The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to 131) (p < 0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p < 0.001), but there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group. Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods (p = 0.011 and p < 0.001, respectively). The health-related quality of life measure was in favour of the total hip replacement group but did not reach statistical significance (p = 0.818 at four months and p = 0.636 at 12 months).

These results indicate that a total hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.

Background. Thrombosis is a rare complication for the single orthopaedic surgeon. The objective for this study was to determine the incidence of thromboembolism after orthopaedic surgery at Söder Hospital.

Methods. All patients operated on during 1997–2000 (n= 25284) were given a short questionnaire regarding postoperative complications. The patients were asked to return the form at 6 weeks. About 50% of the forms were returned spontaneously. A research nurse contacted the rest of the patients. The questionnaires were compared with patient’s charts. An orthopaedic surgeon judged if the complication was related to surgery.

Results. 99.5% of the surveys were returned. 0.78% deep vein thrombosis (DVT) and 0.20% pulmonary emboli (PE) were radiographically diagnosed. DVT mean age was 59.6 and PE 74.7 years. Median DVT detection time was 18.0 and PE 20.6 days. DVT and PE incidence was higher in lower extremity compared to upper extremity surgery. DVT incidence in Achilles tendon ruptures (9.5%), knee replacement (5.8%), pelvic fractures (4.8%) was high.

Conclusions. Thromboembolism incidence in orthopaedic surgery was low. However, some surgical procedures had a high DVT incidence. The results of this study imply the need for adjusting thromboprophylaxis according to the surgical procedure.

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report).

General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D_index score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001).

In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction.

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).

The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D_indexscore) was significant in both groups compared with that before the fracture (p < 0.005).

Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.

The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.

The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery. We have studied 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck. They were randomly placed into two groups, treated either by internal fixation (IF) with two cannulated screws or total hip replacement (THR). None showed severe cognitive dysfunction, all were able to walk independently, and all lived in their own home. They were reviewed at four, 12 and 24 months after surgery. Outcome measurements included hip complications, revision surgery, hip function according to Charnley and the health-related quality of life (HRQoL) according to EuroQol (EQ-5D).

The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications (36% and 4%, respectively; p < 0.001), and the number of revision procedures (42% and 4%, p < 0.001). Hip function was significantly better in the THR group at all follow-up reviews regarding pain (p < 0.005), movement (p < 0.05 except at 4 months) and walking (p < 0.05). The reduction in HRQoL (EQ-5D _index score) was also significantly lower in the THR group than in the IF group, comparing the pre-fracture situation with that at all follow-up reviews (p < 0.05).

The results of our study strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck.

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw.

The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms.

Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work.