Introduction: A secular trend in hip fracture incidence shows a decrease in Europe and North America. Although the results are age adjusted – is there a decreasing trend in all age groups or is just the fracture curve drifting?

Material and Methods: In this population based material includes all hip fractures 1993–2005, in men and women, age 50 years or older admitted to the University Hospital in Ume̊ in the northern part of Sweden. The total numbers of hip fractures in this age group over this 13 years period were 2919 (909(31%) in men and 2010 (69%) in women). The crude numbers of fractures and incidence were mean value over the time periods 1993–96 and 2001–05.

Results: The age adjusted incidence were showing a declining trend X 1993–96, Y 1997–2000, Z 2001–05(ska kolla med Hans hur jag räknar ut). The crude numbers of hip fractures per year are more or less constant 93–96 222,25 (150 women and 72,25 men), 01–05 221,1 (152,4 women and 68,8 men) When analyzing the age groups separately a 50% increase in crude fracture rate was noted in women age 90 or older (11,5 hip fractures/year(93–96) and 24,6 hip fractures/year(01–05). The latter fracture rate can be compared with the crude number of hip fractures in women age 75–79 (27,2 fractures/year 2001–05).

The incidence was also increasing during this period of time, from 270/10.000 to 390/10.000 among the women age 90 or older.

In men there were a declining trend in both incidence and crude numbers, only a small increase of crude fractures were noted among the oldest men age 90 or older.

Conclusion: Though the age adjusted incidence shows a declining secular trend the crude facture rate and incidence are increasing in the oldest women age 90 year or older. Changes in this particular age group does not affect the age adjusted incidence when analyzing the whole population age 50 years or older. (kolla upp) Women 90 years and older do now account for the same amount of hip fractures every year as the women 75–79 years. There seem to be a drifting in the hip fracture incidence pattern towards older. It is therefore important to analyze secular changes in incidence separately in different age groups so that changes in fracture pattern can be identified.

A prior fragility fracture is one of the strongest predictors for a subsequent one, and this should be a target for secondary fracture prevention. All injured patients admitted to the emergency floor, Ume̊ University Hospital, Sweden, were registered. Between 1993–2004, there were 113,668 injury events, including 29,190 fracture events (one or more fractures at the same time), of whom 12,635 patients were _ 50 years. 1,994 of them had at least two fracture events; 500 had 3; 131 had 4; 35 had 5; and 11 had _ 6 fracture events. Mean age at the baseline fracture was 72.2 years and 75.5 at the second one. Thus, over 50 years of age, not less than 37% of all fractures were serial fractures, and 20% of the patients are serial fracturers.

Hip and radius fracture were the most common ones, but 20% were fractures not traditionally labelled as fragility fractures. However, since more than 78% were caused by falls in the same level, most presumably have a fragility component.

The interval between the two first fractures was longer than reported in several previous studies, mostly on patients participating in clinical trials. However, our material is population-based and unselected, since there is just one trauma facility in the area, and the general population is healthier than in-hospital or trial patients. On the other hand, there is a cut-off bias, so the interval is likely to be even longer.

Interestingly, the difficult-to-treat hip fracture was the second common baseline fracture, the most common subsequent one, and hip-hip fractures were the most common combination, not less than 8.5% of the serial fractures. It is therefore clinically important to use the information provided by the fracture event, a fragility fracture may actually be regarded as a biomechanical test or a natural experiment. Trauma units, therefore, have an onus to screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients, but alas this is rarely done. A similar neglect of secondary prophylaxis and treatment after cardiovascular disorders would be an outrage! Secondary prevention is especially important since serial fractures are so common, often preventable, having a high impact on health-related quality of life

Even in patients with pronounced osteoporosis, fragility is rarely a sufficient or necessary cause of fracture. Almost always a trauma involved. Exposure to injuries varies with eg sociologic and climatologic. Since 1993 all injuries admitted to Ume̊ University hospital, Sweden, up to 58 parameters have been registered, eg mechanism, environment, involved products and diagnoses. The 12-year population-based injury register now comprises113,668 injuries (29,190 fractures).

The absolute number of fractures is important from a practical clinical point of view. Most fractures occur in the extremities of life, perhaps due to both a weaker skeleton in growth and senescence and to exposure to injury. The earlier fracture peak in girls is caused by their earlier growth spurt. The higher and broader fracture peak in boys also reflects behavioural factors. Men continue to have more fractures until around 50, showing the effect of menopause.

Radius fracture incidence in Ume̊ was about 15% higher than in Malmö, Sweden. But surprisingly hip fracture incidences were in the same order of magnitude in Malmö and Ume̊, which is remarkable considering the 8o latitude difference. But this may be explained by the different injury mechanisms in the two fractures

Low energy-trauma (fall in the same level) was most common in the extremities of life. However, most of the other mechanisms also involved low-moderate trauma, and high-energy trauma was rare. In this sub arctic register, outdoor slips was a common cause of fracture in middle age but as in other materials such injuries became less common with age.

A further detailed analysis of the mechanisms causing fractures and soft tissue injuries could be a useful tool in prevention of fall injuries. Is it possible to identify frequent fallers or other accident prone people, before an incapacitating injury? This would indeed be a major public health challenge

Fracture is the only clinically relevant aspect of osteoporosis—a major public health problem in many countries. The strongest predictor for a new fragility fracture is a previous one. For instance, a patient with one osteoporotic vertebral compression fracture has about a seven-fold increased hip fracture risk; a patient with two compression fractures a 14-fold hip fracture risk. Today, we have evidence based and efficient osteoporosis drugs as well as non-pharmacologic methods for fracture prophylaxis. In risk group patients it often is possible to halve the fracture risk.

The orthopaedic surgeon is the first and sometimes the only doctor a fracture patien sees. Therefore, as orthopaedic surgeons, we have a great opportunity—and indeed an onus—to identify patients with increased fracture risk, and to do something about it.

Imagine patients with myocardial infarction or stroke discharged from hospital without blood pressure control or having a biochemical profile taken? Such negligence is, alas, not uncommon for patients with fragility fractures. We must think in terms of absolute fracture risk, and implement today’s evidence based knowledge.

Secondary prophylaxis should be an integrated part in fracture treatment. And this calls for a multidisciplinary and multiprofessional teamwork including surgeons, geriatricians, endocrinologists and general practitioners, as well as nurses, physiotherapists and a wide range of other paramedical specialists. Such “fracture chains” will reduce the number of unnecessary and preventable injuries and will have a great impact in terms of cost and suffering. This symposium will give an overveiw of fracture-preventing strategies.

Radius fracture is the earliest and one of the most common symptoms of osteoporosisò1/6 of fractures seen in the emergency roomòand many patients with distal radius fractures would benefit from osteoporosis treatment to prevent future fractures. Nearly 80% are women, most frequent between 60–70 years of age; men have a more flattened incidence curve.

As to classification, distal radius fractures span a wide spectrum, but the sheer bulk of them calls for a simple and robust classification with a low interobserver error. Older’s classification gives an indication of the risk for redislocation, and perhaps the presence/localisation of comminution in the distal/metaphyseal areas are more prognostic than the dislocation per se in unstable fractures.

Despite improved surgical treatment, most series still report dissatisfaction rates around 20% with significant complications. One reason is that the population of patients with fragility fractures is so heterogeneous in terms of autonomy, cognitive function, and functional demands. Although anatomy does correlate with function, a stratification in background factors seems to be reasonable. The chronological age of the patient and the radiological classification grade of the fracture are often not the most important factors in terms of functional outcome, health-related quality of life and patient satisfaction in the long run.

The indications for reduction and external/internal fixations are still unclear, but there has been clear trend towards a more active approach, and a combination of different surgical techniques. But since it is still unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes, there is a need for evidence for the management of these fractures in terms of efficacy (clinical trials) and effectiveness (general practice).

The computer and telecommunications revolution has barely begun, although it has already profoundly changed our daily lives. But health care is still regrettably unplugged compared with other industries. Why? There are several obvious answers. For one thing, modern medicine is both complex and fragmented. And the medical profession has a long tradition and a strong ethos, not easily influenced by IT nerds. Also, security and patient integrity as well as other legal aspects put limits on what is feasible and desirable. The collapse of the dot.com business and the numerous accounting scandals have certainly not increased the profession’s confidence of internet.

Yet, documentation in today’s health care is obsolete: at the same time redundant and insufficient. Access time for paper documents are often measured in days or weeks rather than in milliseconds. This slow communication technology is bad for our patientsòat a time when the sheer magnitude of information necessary for medical decision-making is increasing exponentially. Another aspect is research and quality control. No manager of a manufacturing industry would keep his/her job without keeping the board happy with hard data on the quality of what is produced. How about medicine?

This symposium aims at giving a smorgasbord of IT applications in orthopaedic care, quality control and research. We will also discuss perhaps the most important question: what do we want the new technology to do for our patients and for orthopaedic surgery? Complications of limb salvage

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 studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact.

We report a prospective study of 232 consecutive patients with hip fractures. All were over 64 years of age and living independently before admission to a geriatric orthopaedic ward. We assessed the value, at admission, of predicting factors for independent living at one year after injury.

The most important factors were: (1) preinjury function in activities of daily living (grade A or B on the Katz et al (1963) scale); (2) absence of other medical conditions which would impair rehabilitation; and (3) cognitive function better than 7 on the Pfeiffer (1975) mental questionnaire. The odds ratios (95% CI) for these three predictors were 3.5 (1.3 to 9.1), 2.9 (1.3 to 6.1) and 2.4 (1.9 to 4.9), respectively. When all predictors were positive at admission, 92% were living independently at one year; with one, two or three negative predictors, the percentages living independently were 76, 61 and 27, respectively.

The median values of the total number of days in hospital, irrespective of diagnosis, during the first year were 12, 24, 29 and 149 days for the four groups. The mortality at one year was predictable on admission only by the number of medical conditions: with no other diagnosis than the fracture the mortality was 0%; with one or two additional conditions the mortality was 14%; and with three or more additional diagnoses it was 24%.

These simple and robust predictors can be used to optimise resources for rehabilitation.

The axis of the talo-crural joint was analysed by roentgen stereophotogrammetry in eight healthy volunteers. Examinations were performed at 10 degrees increments of flexion and pronation/supination of the foot as well as medial and lateral rotation of the leg. Results indicate that the talo-crural joint axis changes continuously throughout the range of movement. In dorsiflexion it tended to be oblique downward and laterally. In rotation of the leg, the axis took varying inclinations between horizontal and vertical. All axes in each subject lay close to the midpoint of a line between the tips of the malleoli. Our study indicates that the talo-crural joint axis may alter considerably during the arc of motion and differ significantly between individuals. This prompts caution in the use of hinge axes in orthoses and prostheses for the ankle.