Session 4: Trauma 1
Torsdag den 24. oktober
09:00 – 10:30
lokale: Helsinki/Oslo
Chairmen: Lonnie Froberg / Frank Damborg
31. Does choice of treatment of midshaft clavicle fractures affect early return to work?
Ban Ilija , Gromov Kirill, Troelsen Anders
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Optimal treatment of displaced midshaft
clavicle fractures is debatable. Most
patients suffering a displaced midshaft
fracture are young males with a high
physical demand including a demand of
early return to work. Whether choice of
primary treatment affects the ability to
return early to work is unknown. Primary
surgical treatment has become popular
and the potential of early return to work
has been used as an argument to favour
surgical treatment.
Purpose / Aim of Study: To investigate whether choice of
primary treatment, operative or
conservative, of acute, displaced,
midshaft clavicle fractures affect early
return to work.
Materials and Methods: This study presents secondary
endpoints from a randomised controlled
trial where surgical treatment with a
superior locking plate is compared to
non-surgical treatment with one-year
follow-up. Early return to work is
defined as return to pre-fracture work
status at the six-week follow-up.
Findings / Results: A total of 63 patients (57 males) were
enrolled in the study (median age 38
years, range: 19-63). 35 patients were
allocated to non-surgical treatment and
28 patients were treated surgically. The
two groups were comparable with
respect to age, sex and ASA score (p-
values: 0.31, 0.57 and 0.90). At time of
enrolment a total of 58 of 63 patients
were working. At 6-weeks follow-up 22
of 31 patients treated conservatively
and 25 of 27 patients treated surgically
had returned to their pre-fracture work
status (p=0.03).
Conclusions: Choice of operative primary treatment of
acute, displaced, midshaft clavicle
fractures does seem to be associated
with a higher frequency of early return
to work. However, multiple other factors
and longer term outcome should be
considered in the choice of treatment.
32. Feasibility of implant-tracking in orthopaedic surgery: High completeness and minimal time consumption.
Heidi Poulsen, Kirill Gromov, Peter Gebuhr, Anders Troelsen
Orthopedics, Hvidovre Hospital; Orthopedic, Hvidovre Hospital
Background: Currently no methods for tracking of
implants, allowing intelligent monitoring of
quality, exist. At present surgeons and
administrators rely on implant labels in
patient charts. In this study we introduce an
online implant tracking system to be used
with existing quality monitoring databases
Purpose / Aim of Study: We evaluate the introduction of an implant
tracking system using unique implant
barcodes, and evaluate the potential for
continuous implant tracking and time
consumption associated with this process
Materials and Methods: An implant tracking system was
developed by Procordo Aps® and
implemented as an addition to the Danish
Fracture Database (DFDB). Orthopaedic
implants used during surgery are
scanned in the operating room (OR)
using unique implant barcodes and are
linked to the specific procedure enter into
DFDB by the operating surgeon. We
evaluated completeness of implant scans
during a one-month period at two ORs at
our institution. We also measured time
consumption for experienced and
untrained OR staff while scanning trauma
and arthroplasty implants
Findings / Results: A total of 21 separately packed implants
were used during the study period at the two
OR’s combined. 20 of these implants were
successfully scanned (95%) and 18 were
linked correctly to the surgical procedure
(86%). When scanning implants for revision
THR surgery and trochanteric nail surgery
untrained OR staff used on average 208
and 117 seconds, respectively. This was
significantly reduced (p<0.05) to 55 and 35
seconds respectively in the hands of an
experienced OR nurse
Conclusions: It was possible to introduce specific implant
tracking of orthopaedic implants at two
operating rooms in one orthopaedic
department, with 95% of possible implants
being scanned shortly after introduction of
the system. Time consumption performing
these scans by the OR staff was minimal
33. Virtual-reality simulation for the assessment of skills in hip fracture surgery
Poul Pedersen, Henrik Palm, Lars Konge
Centre for Clinical Education, Rigshospitalet, University and State hospital of Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Denmark
Background: Unsupervised junior surgeons have been
shown to be a risk factor for reoperations
among hip fracture patients. The need for
improved education is increasingly
acknowledged, and virtual-reality simulation-
based surgical training might improve initial
skills. A reliable simulation test would make it
possible to assess and certify junior
surgeons before proceeding to supervised
practice on patients.
Purpose / Aim of Study: The aim of the study was to develop a
reliable simulation-based test for internal
fixation of hip fractures.
Materials and Methods: Twenty physicians from one orthopaedic
department were divided into two groups of
ten untrained novices and ten experienced
orthopaedic surgeons. Each physician was
tested on three procedures regarding
internal fixation of an undisplaced femoral
neck fracture: Two screws, two hookpins
and a sliding hip screw. Simulator metrics
with discriminatory abilities were identified,
including a combined score for implant
position, use of image intensifier etc. By
using the contrasting groups method a
pass/fail-level was determined and its
consequences explored.
Findings / Results: The percentage of maximum combined
score (PM-score) was the only simulator
metric that showed significant differences
between the two groups. The PM-score
showed an inter-case reliability of 0.83
between the three procedures. The mean
PM-score was 31% (SD 32) for the novices
and 76% (SD 10) for the experienced
surgeons (p<0.001). The tests pass/fail-
level was a PM-score at 58%, resulting in
none of the novices passing the test and a
single experienced surgeon failing the test.
Conclusions: It was possible to create a reliable test on
the simulator. The test and the pass/fail-level
could help assess and guarantee the quality
of future junior surgeons in simulation-based
training programs before proceeding to
supervised practice on patients.
34. Breakage at the proximal screw in long Gamma 3 titanium intramedullary femoral nail
Nikolaj Sode, Lonnie Froberg, Michael Brix
Department of Orthopedics, Odense University Hospital, Denmark
Background: Internal fixation with a long anterograde
intramedullary femoral nail is a well
established surgical technique for unstable
intertrochanteric and subtrochanteric
fractures of the femur. The nail is designed
to be walked upon for at least 6 months
before breakage. However; it is known that
titanium loose up to 50% strength if
scratches occurs during insertion of the K-
wire or the collum screw.
Purpose / Aim of Study: We report a series of 8 patients
osteosynthesised using long Gamma 3
titanium nails which all failed with breakage
in the proximal cervical screw opening.
Furthermore, 4 of these patients had a
similar failure of the secondary nail after
reoperation, for a total of 12 broken nails.
Materials and Methods: The study is a retrospective case series of
patients treated for unstable
intertrochanteric or subtrochanteric
fractures with the long Gamma 3 titanium
nail in the Southern Region of Denmark,
from december 2010 to june 2012.
Information was gathered through medical
records and x-rays.
Findings / Results: The study included 8 patients, 4 female and
4 males representing 6 AO 31A3 fractures
and 2 31A2 fractures. The median age was
68 years (35-90 years) and median BMI 25
(21-38). Median time to failure was 4 months
(2-18 months) and median time to follow up
22,5 months (13-27 months). All nails were
11 mm in diameter. 5 patients had additional
cables around the femoral bone. Post
operative tip-apex distance was <25 mm in
all cases. One patient had jamming of the
collum screw.
Conclusions: We experienced an unexpected high
number of nail breakage. We recommend
careful insertion of the collum screw to avoid
damage and thereby reducing tre strength
of the nail.
35. Anamnestic medicine errors among hip fracture patients can be reduced by a pharmacist / pharmaconomist
Morten B. Andersen, Sanne H. Johansen , Marianne K. Jensen, Lise J. Nørregaard , Susanne D. Olsson, Henrik Palm
Department of Orthopaedic Surgery and The Hospital Pharmacy, Copenhagen University Hospital Hvidovre, Denmark; The Hospital Pharmacy, Copenhagen University Hospital Hvidovre, Denmark; Department of Orthopaedic Surgery , Copenhagen University Hospital Hvidovre, Denmark
Background: Hip fracture patients often have severe
co-morbidity and use multiple types of
medicine. Studies have shown that
medicine anamnesis is often
inadequately recorded on admission
with risk of discrepancies and
complications.
Purpose / Aim of Study: The purpose was to compare the
medicine anamnesis recorded among
hip fracture patients as usual in the
emergency room (ER) with a
secondary recording in the orthopedic
department by a pharmacist /
pharmaconomist.
Materials and Methods: 200 consecutive hip fracture patients
(78% female, mean age 79 (range 22-
97)) admitted through the ER from
Sept 2012 to March 2013 were
included. The electronic ER medicine
anamnesis was corrected within 48
hours in the orthopedic department by
a pharmacist / pharmaconomist using
min. 3 of following sources: Patient,
patient record, national medicine
database (PEM/ FMK-online),
pharmacy, general practitioner and
lists from relatives, visiting nurses or
home care services. Only corrections
accepted by medical doctors were
recorded as errors.
Findings / Results: On average, each patient used 6
different drugs with 2 errors recorded.
The total 413 errors was distributed as
209 (51%) drug omissions, 67 (16%)
false prescribing, 64 (15%) false
doses, 61 (15%) clinically relevant
improper dosing time and 12 (3%)
other errors. Most often errors were
seen among ATC groups: nervous
system (N), alimentary tract and
metabolism (A), cardiovascular system
(C), blood and blood forming organs
(B) and respiratory system (R).
Conclusions: This study confirms that medicine
anamneses among hip fracture
patients are inadequately recorded on
admission, where the available time
and sources for information are
suboptimal in the nowadays Danish
health system. Secondary medicine
anamneses by a pharmacist /
pharmaconomist can in our eyes
reduce the incidence of medicine
errors and improve patient safety.
36. Ilizarov salvage procedure following failed osteosynthesis of the patella.
Tine Nymark, Lars Schjøtz, Ole Skov
Orthopedic, Odense University Hospital
Background: Patella fracture comprises approx 1% of all
skeletal fractures. Failure of osteosynthesis
of the patella fracture is rare, but can result
in disrupted extensor mechanism, deep
infection of the knee and soft tissue defects.
Patellectomy, partial or complete, knee
arthrodesis or femoral amputation has been
described as treatment
Purpose / Aim of Study: We wanted to improve the treatment of failed
osteosynthesis of the patella without
compromising the knee joint.
Materials and Methods: From 2001-now 6 patients, mean age 68
years (range 49-77 years) with deep
infection of the knee and failed
osteosynthesis of the patella transferred to
out unit 47 days (15-111 days) after primary
operation. They had recieved 2 to 5 surgical
revisions.
We performed debridement, total
synovectomia of the knee, revised the
fracture and then stabilised the fracture
using the Ilizarov technique, with two K-
wires perpendicular to the major fracture
plane mounted in two half-rings. In one case
a gastrocnemius flap was used to cover an
extensive tissue defect. Patients were
allowed immediate weight-bearing. The knee
was immobilised for two weeks, then allowed
0-30 degrees in week 3 and 4, 0-60 degrees
in week 5 and 6.
Findings / Results: The Ilizarov was removed after 60 days (38-
103). At the end of follow-up, 218 days (134-
347) patients could extend between 0-5
degrees and bend the knee between 90-110
degree.
Conclusions: Using the Ilizarov technique proved effective
in the treatment of these patients. However
since the condition is rare, the treatment
should be centralised to departments with
expertice in treating such conditions as well
as the possible need for plastic surgery.
37. Healing and morbidity in femoral and tibial non-unions when using reamer-irrigator-aspirator system
Søren Kjær Petersen, Morten Schultz Larsen
Orthopedic Surgery, medical student, University of Southern Denmark; Orthopedic Surgery, Odense University Hospital
Background: Non-unions often needs autologous bone
grafts as part of treatment. This is
traditionally harvested from the iliac
crest(ICBG). Limited graft volume and donor
site morbidity are drawbacks to this method.
With RIA it is possible to harvest larger
amount of graft material and only few
complications are described.
Purpose / Aim of Study: The purpose of this survey is to evaluate
bone healing and donor site morbidity for RIA
and ICBG.
Materials and Methods: 21 consecutive patients were treated with
RIA in the period of 05.10.2010-21.10.2012.
25 patients treated with ICBG were chosen
as controls and matched among other due to
age, gender and location of non-union. X-
rays and reports were retrospectively
studied with respect to healing and
complications. Crude assessment of the
needed amount of graft material was based
on preoperative x-rays. Donor site pain was
evaluated through telephonic interview.
Findings / Results: 8 of 9 femoral non-unions treated with
RIA achieved union while 6 of 6 treated
with ICBG. On tibia 10 of 11 in the RIA
group achieved union while 18 of 19 in
the ICBG group. There were no
significant difference in healing between
RIA and ICBG. In 16 of 21 RIA patients
graft material exceeding assessable
volume compared to anterior ICBG.
Based on telephone interview ICBG
showed a tendency to have more donor
site pan 3 days and one month
postoperative, but the difference was
not significant.
One adverse event is reported. One
patient got a diaphyseal, femoral fissure
during gait that required intramedullary
nailing.
Conclusions: This retrospective survey has shown no
difference in union rates using RIA and ICBG
in treating lower extremity non-unions.
Patients treated with RIA experience less
pain compared to IBCG. Besides larger
amounts of graft material can be harvested
from the femur using RIA, though severe
complications can occur.
38. Preoperative CT scan of tibial diaphyseal fractures distal to the isthmus influences treatment.
Paulius Nekrasas, Juozas Petruskevicius, Søren Kold
Orthopaedic, Aalborg University Hospital
Background: In 2012 the Nordic radiation authorities
raised concern about the increased use of
computed tomography.
Purpose / Aim of Study: To investigate whether preoperative CT
scanning of tibial diaphyseal fractures
below the isthmus changes fracture
treatment.
Materials and Methods: Retrospective analysis of 34 tibial
diaphyseal fractures distal to the isthmus.
Inclusion criteria: 1) a tibial diaphyseal
fracture distal to the isthmus in a skeletally
adult; 2) both preoperative AP and lateral x-
rays as well as a preoperative CT scan
including the ankle joint had been
performed. Exclusion criteria: Fractures
which from preoperative x-rays could be
classified as a tibial Pilon fracture.
Findings / Results: The tibial fractures were classified from
preoperative x-rays according to the
AO classification: 9 type 42A, 2 type
42B, 1 type 42C, 4 type 43A, 13 type
43B, 5 type 43C. In 14 out of 34 cases
the AO classification was changed after
additional preoperative CT scan. The
main diaphyseal fracture was fixed with
a intramedullary nail in 11 cases,
circular external fixator in 19 cases and
other type of osteosynthesis in 4 cases.
In 10 out of 34 cases a fracture
component at the ankle joint was treated
with additional screw fixation. In 9 out of
34 cases the preoperative CT scan
revealed a fracture component at the
ankle that was unseen on preoperative
x-rays and 5 of those needed additional
screw fixation. There were 32 of 34
patients who had an ipsilateral fibula
fracture. The level of fibular fracture
was 148 (106) mm above the tip of
lateral malleolus for the 20 patients with
an intra-articular fracture versus 204
(134) mm for the 12 patients without an
intra-articular fracture (two-sample t
test, p = 0.2).
Conclusions: Preoperative CT scan of tibial diaphyseal
fractures distal to the isthmus is justified as
the CT led to change in surgery in 5 out of
34 cases.
39. Health related quality of life after severe trauma – comparison of EQ-5D with norm scores 15 years after injury
Thomas Laursen, Morten Wad, Sidsel Fruergaard, Claus Falck Larsen, Benny Dahl
Orthopaedic Surgery, Rigshospitalet; Trauma Center, Rigshospitalet
Background: Previously, outcome studies of trauma patients have primarily focused on short-term survival but
an increasing number of studies have focused on long-term outcome and health related quality of
life (HRQL). Most of these studies have shown a reduced HRQL in severely traumatized patients
up to 5 years after injury but long-term studies are few.
Purpose / Aim of Study: The purpose of the present study was to compare HRQL with norm scores 15 years after severe
trauma.
Materials and Methods: Patients more than 18 years of age, admitted to the emergency department at Rigshospitalet from
March 1996 through September 1997 were included in the study. In May 2012 survival status was
obtained and the Danish version of the European Quality of Life-5 Dimensions (EQ-5D)
questionnaire, was mailed to all patients alive. The EQ-5D results were compared with results
from the general population.
Findings / Results: Of the original 171 patients, 92 patients received the EQ-5D questionnaire. 46 patients responded
and 41 questionnaires were available for analysis. The average EQ-5D index score in the trauma
population was significantly reduced compared to the index score in the Danish norm population;
0.671 vs. 0.873 respectively (P = 0.000). Comparing the EQ-5D index scores in patients with less
severe and severe injury showed that that the median EQ-5D index score in patients with ISS <16
was 0.824 vs. a median score of 0.660 in patients with ISS ≥16 (P = 0.022).
Conclusions: Fifteen years after severe trauma patients
report reduced HRQL and Injury severity
predicted poor HRQL. Further studies are
required to assess the possible impact of
co-morbidities or additional injuries.
40. Complications after osteosynthesis of distal radius fractures using a volar locking-plate
Roland Knudsen
Orthopaedic, Odense University Hospital
Background: Open Reduction and Internal Fixation (ORIF)
of distal radius fractures using a volar
locking plate has become one of the most
common acute operations performed. There
is only a limited amount of literature, which is
describing the possible complications.
Purpose / Aim of Study: Our aim was to register which complications
patients suffered from following the above
mentioned operation, and how often these
complications occurred.
Materials and Methods: We included all patients (165) who in 2008
and 2009 had a distal radius fracture
operated on in Kolding Hospital using a volar
locking plate. We did a retrospective cohorte
study using the patient’s notes and X-rays.
We registered any complication, which
needed intervention.
Some patients were operated using a
“Locking Compression Plate” (LCP) and
others using a “Distal Volar Radius plate”
(DVR).
Findings / Results: 30/165 (24%) patients experienced a
complication, which needed intervention. Of
these 8 patients experienced more than one
complication.
Patients, who were operated using a LCP
plate experienced more complications than
those operated using a DVR plate. The
difference was however not significant
(p=0.054).
Conclusions: We registered more complications, which
needed interventions, than we expected.
There was a trend towards more
complications when using LCP, but the
difference was not significant apart from
one subgroup of fractures.
When 24% of patients experiences at
least one complication, which require
intervention, care must be shown not to
over-treat these fractures. One must
remember that some of these fractures
can treated conservatively with no or
limited sequelae.
Other studies have shown similarly
results regarding the frequency of
complications.
41. Urinary tract infections and complications among hip fracture patients treated within a multimodal rehabilitation concept
Pia Søe Jensen, Nicolai Bang Foss, Ulrich Stab Jensen, Dorthe Gaby Bove, Henrik Palm, Henrik Kehlet
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anaesthesiology, Copenhagen University Hospital Hvidovre; Department of Microbiology, Copenhagen University Hospital Hvidovre; Section of Surgical Pathophysiology,, Rigshospitalet, Copenhagen University
Background: Urinary tract infections (UTI) are common
among hip fracture patients, but whether this
is associated with complications or
prolonged hospitalization is not clear. The
treatment of hip fracture patients includes
early surgery, regional anaesthesia, early
mobilisation, enhanced oral nutrition and
urinary bladder catheters, which could
cause nosocomial UTI.
Purpose / Aim of Study: To identify the incidence of pre-admission
and nosocomial UTI, and the association with
serious complications among hip fracture
patients treated according to a well-defined
multimodal rehabilitation concept, including
urinary bladder catheters in the perioperative
period.
Materials and Methods: Prospective observational study of 424 hip
fracture patients aged >65, with urine
culture tests on admission and the seventh
postoperative day. All patients were treated
with an indwelling urinary bladder catheter
until the fourth postoperative day. Self-
reported clinical symptoms on admission
related to UTI were individually assessed, as
were hospitalization length and serious
postoperative complications such as
pneumonia, delirium, cardiovascular events,
renal failure, infections and reoperation.
Findings / Results: The incidence of admission bacteriuria (104
per ml, except e-coli 103) was 32%
(137/424) with no significant association to
self-reported clinical symptoms. The
incidence of nosocomial bacteriuria was
58% (124/214; 73 without later urine culture
test). Regression analysis showed no
association between nosocomial bacteriuria
and complications or prolonged
hospitalization.
Conclusions: The incidence of preadmission and
nosocomial bacteriuria was confirmed to be
high among hip fracture patients, but not
associated with self-reported clinical
symptoms or decreased outcome.