Session 9: Trauma
Torsdag den 23. oktober
13:00 – 14:30
Lokale: Helsinki/Oslo
Chairmen: Peter Toft Tengberg / Søren Kold
85. Orthogeriatric collaborative improves 30 day mortality and quality of care after hip fracture in the elderly: a nationwide cohort study
Pia Kjær Kristensen, Theis Muncholm Thillemann, Kjeld Søballe, Søren Paaske Johnsen
Department of Orthopaedics , Hospital Horsens; Orthopaedic surgery , University Hospital Aarhus; Orthopaedics , University Hospital Aarhus; Department of Clinical Epidemiology, University Hospital Aarhus
Background: Orthogeriatric collaborative has been
linked with better clinical outcomes for
hip fracture in clinical trials, however
little is known about the impact of
orthogeriatrics on quality of care and
clinical outcomes among patients with
hip fracture in a routine setting.
Purpose / Aim of Study: We examined the association between
orthogeriatrics and 30-day mortality,
quality of care, surgical delay and
length of stay among patients with hip
fracture.
Materials and Methods: Using prospectively collected data from
the Danish Multidisciplinary Hip
Fracture Registry, we identified 12,065
patients ≥65 years who were admitted
with a hip fracture between 1. March
2010 to 30. November 2011. The exposure
was divided in two groups; Orthopaedic
ward with geriatric or medical
consultant service on request and
orthogeriatric collaborative where the
geriatrician is integrated into the
orthopaedic team with nurses,
physiotherapist and the orthopaedic
surgeon. The primary outcome was 30-day
mortality. Secondary outcome included
quality of care assessed using six
process indicators, surgical delay and
length of stay. Data was analyzed using
regression techniques while controlling
for potential confounders.
Findings / Results: The 30-day mortality was 9.4 % and 12.0
% for orthogeriatric and orthogeriatric
ward. Admittance to an orthogeriatric
ward was associated with decreased
30-day mortality (adjusted odds ratio =
0.69 (95% CI: 0.54-0.88)). Furthermore,
patients had higher relative risk for
systematic pain assessment, for
receiving basic mobility assessment, for
a post discharge rehabilitation program,
for anti-osteoporotic medication and for
prevention future fall accidents. Length
of hospital stay and surgical delay were
similar in the groups.
Conclusions: Admittance to an orthogeriatric ward was
associated with decreased mortality
rates and improved quality of care.
86. Tranexamic Acid (TA) Reduces Overall Blood Loss in Unstable Trochanteric Fractures Treated with Intramedullary Nailing (IMN)
Peter Toft Tengberg, Henrik Palm, Nicolai Foss, Thomas Kallemose, Anders Troelsen
CORH, Hvidovre Hospital; Anesthesiologic dept, Hvidovre Hospital
Background: Patients with unstable trochanteric fractures
treated with intramedullary nailing (IMN)
suffer a major overall blood loss. This is
associated with risk of postoperative anemia
resulting in increased morbidity, mortality and
prolonged hospitalization. Tranexamic Acid
(TA) has shown documented effect, with
reduced blood loss, in other fields of
orthopaedics, such as arthroplasty surgery.
Purpose / Aim of Study: The aim of the study was to test if TA can
reduce overall blood loss in patients with
unstable trochanteric fractures treated with
a short IMN.
Materials and Methods: The study is a 2-arm, double blinded,
randomized placebo controlled trial with
two groups. The inclusion period was
September 2011 to June 2014. Patients
with unstable trochanteric fractures
scheduled for a short IMN were eligible
for inclusion. Patients in the intervention
group were given a 1 g bolus of TA
during initiation of anesthesia and 3 g of
TA in 1 l of saline over 24 hours
postoperatively. The placebo group was
given a similar regime, without TA.
270 patients were approached for
inclusion. Of these, 75 were included,
with a final study group of 73 after 2
postoperative inclusions.
Findings / Results: There were 51 (71%) women. Mean age
was 77.3 (SD: 12.3). Mean blood loss in the
intervention group (33 patients) was 1410,9
ml (1001,4) compared to a mean blood loss
of 2100,4 (1152,6) in the placebo group
(p=0.008, t-test). There were no cases of
in-hospital, thromboembolic events in either
group.
Conclusions: We found a statistically significant reduction
in the overall blood loss close to 700 mL for
patients treated with TA. TA seems to be an
effective blood saving strategy for this
group of hip fracture patients and should be
considered in future treatment regimens. Our
data revealed no safety concerns.
Further studies should focus on optimal
timing and dose of TA.
87. Validation of fracture treatment codes from the Danish National Patient Registry: Implications for The Danish Fracture Database
Morten Jon Andersen, Michael Kuhlman, Michael Brix, Kirill Gromov, Anders Troelsen
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: More than 99% of all public discharges are
recorded in the Danish National Patient
Registry (NPR), however data have been
proven to have a degree of uncertainty. The
Danish Fracture Database (DFDB) was
established with the goal of recording all
fracture surgery in Denmark. With the
growing amount of data in DFDB, a viable
way of verifying completeness and validity is
needed.
Purpose / Aim of Study: The aim of this study was to validate the
NPR treatment codes regarding fracture
surgery to allow for continuous monitoring of
DFDB data.
Materials and Methods: At our institution the diagnosis and operation
codes are reported directly from the
operation-booking programme (OBP) to
NPR. A list of 500 consecutive patients
operated for fractures from January to April
2012 was created from the OBP. Patient
charts and x-rays where reviewed by the
authors. The treatment codes were
considered correct when codes and the x-
ray assessment matched exactly. The
anatomic region of the diagnosis or
operation was considered correct if the
fracture or osteosynthesis was present in
the region specified by the first four letters in
the code.
Findings / Results: In 16 cases x-rays were missing, 484 cases
was analysed further. The overall validity of
data was 86% (417/484). In 94% (454/484)
the NPR diagnosis code was correct and
the NPR anatomic region was correct in all
but one case. In 91% (440/484) the
operation code was correct and the
anatomic region for the operation was
correct in all but two cases. The correct side
(left/right) was given in 99% (477/484) of
cases.
Conclusions: Diagnosis and operation codes regarding
fracture surgery reported to the NPR
showed very high validity. If the same data
validity of data reported to NPR can be
confirmed for other regions and hospitals in
Denmark NPR data can serve as a way of
verifying completeness and validity in DFDB.
88. Sensitivity and specificity of CT and MRI imaging in occult hip fractures
Martin Haubro, Camilla Stougaard, Trine Torfing, Søren Overgaard
Department of Orthopaedic Surgery and Traumatology, Odense University Hospital; Department of Radiology, Odense University Hospital
Background: The incidence of occult hip fracture
has been estimated to 2-10% using
standard X-ray imaging.
It has been stated that MRI is superior
to CT in detecting occult fracture of the
hip however this statement is based on
case reports and non-controlled
studies of few patients.
Purpose / Aim of Study: To estimate sensitivity and specificity
of CT and MRI examinations in
patients with fractures of the proximal
femur. To determine the interobserver
agreement of the modalities among a
senior consulting radiologist, a resident
in radiology and a resident in
orthopaedics surgery.
Materials and Methods: 67 patients seen in the emergency
room with hip pain after fall, inability to
stand and a primary X-ray without
fracture were evaluated with both CT
and MRI. The images were analysed
by a senior consulting musculoskeletal
radiologist, a resident in radiology and
a resident in orthopaedic surgery.
Sensitivity and specificity were
estimated with MRI as the golden
standard. Kappa value was used to
assess level of agreement in both MRI
and CT finding.
Findings / Results: 15 fractures of the proximal femur
were found. Two fractures were not
identified by CT and four changed
fracture location. Among those, three
patients underwent surgery. Sensitivity
of CT was 0.87; 95% CI [0.60;0.98].
Kappa for interobserver agreement for
CT were 0.46; 95% CI [0.23; 0.76] and
0.67; 95% CI [0.42; 0.90]. For MRI
0.67; 95% CI [0.43;0.91] and 0.69;
95% CI [0.45;0.92].
Conclusions: MRI was observed to have a higher
diagnostic accuracy than CT in
detecting occult fractures of the hip.
Interobserver analysis showed high
kappa values corresponding
substantial agreement in both CT and
MRI.
89. Inter-rater reliability and agreement of the 6-minute walk test in females with hip fractures
Jan Arnholtz Overgaard, Camilla Marie Larsen, Morten Tange Kristensen
Department of Rehabilitation and Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Municipality of Lolland; Research Unit of Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark; Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), Departments of Physiotherapy and, Hvidovre University Hospital
Background: The 6-minute walk test (6MWT) is widely
used as a clinical outcome measure.
However, the reliability and agreement of the
6MWT is unknown in individuals with hip
fractures.
Purpose / Aim of Study: To evaluate the relative inter-rater reliability
and agreement of the 6MWT in individuals
with hip fractures.
Materials and Methods: Two senior physiotherapy students
independently examined (randomized order)
a convenient sample of 20 participants; their
assessments were separated by two days,
and testing followed instructions from the
American Thoracic Society. Hip pain was
assessed with the Verbal Ranking Scale.
Findings / Results: Participants (all women) with a mean
(SD) age of 78.1 ± 5.9 years performed
the test within a mean of 31.5 ± 5.8 days
post-surgery; 10 had a cervical and 10 a
trochanteric fracture.
Excellent inter-rater reliability; ICC2.1 =
0.92 (95% CI, 0.81 - 0.97) was found,
and the standard error of measurement
(SEM) and smallest real difference (SRD)
were calculated as 21.4 meters and 59.4
meters, respectively.
Bland-Altman plots revealed no
significant difference (mean of 3.2 ± 31.5
meters, P = 0.83) between the two
raters, and no heteroscedasticity was
seen (r = -0.196, P = 0.41). On the
contrary, participants walked a mean of
21.7 ± 22.6 meters longer, at the second
trial (P = 0.002).
Participants with moderate hip fracture-
related pain walked a shorter distance
than those with no or light pain during the
first test (P = 0.04), while this was not
the case during the second (P = 0.25).
Conclusions: Excellent inter-rater reliability was found
with a low level of measurement error,
particularly for a group of participants with
hip fractures, as a change of 22 meters can
be considered a real change. The
importance of measuring hip fracture-related
pain during testing seems important when
individuals with hip fracture perform the
6MWT.
90. Surgical delay increases early mortality for patients with proximal femoral fractures. A study from The Danish Fracture Database Collaborators.
Anne Marie Nyholm, KIrill Gromov, Henrik Palm, Michael Brix, Thomas Kallemose, Anders Troelsen
Department of Orthopaedics, Hvidovre Hospital
Background: Surgical delay (SD) of proximal femoral
fracture (PFF) is of interest as some studies
show SD >24 or >48 hours to significantly
increase mortality (MT), while others find no
correlation.
Purpose / Aim of Study: To show if a) SD or b) surgeon’s experience
(SE) increases MT rates for following PFF.
Materials and Methods: We included trochanteric or femoral neck
fractures (AO31A and 31B) from the
Danish Fracture Database, excluding
pathological and high-energy trauma
fractures. Data included age, gender,
American Society of Anesthesiologists
(ASA) score, type of fracture and
osteosynthesis, SE and SD. SE was
defined as “attending or above” or
“below attending”. SD was defined as
hours (h) from radiological diagnostics
until start of surgery. MT data was from
The Civil Registration System. Multiple
logistical regression analysis was used
to calculate MT rates.
Findings / Results: 3595 fractures were included: mean age
81.0 years, 70% were female and 49%
were trochanteric fractures (AO31A).
SD was <12h in 21%, <24h in 70%, <48h
in 92% and <72h in 95% of cases. SE
was “Attending or above” in 49% of all
cases. MT was 10.8% at day 30 and
17.4% at day 90. SD >12h increased
adjusted risk of 30-day MT (OR 1.43,
p=0.02). SD >24h increased adjusted risk
of 90-day MT (OR 1.24, p=0.03). SE
“below attending” increased MT risk at
both day 30 (OR 1.27, p=0.04) and day
90 (OR 1.28, p=0.01). Increasing age and
ASA score, male gender and type of
osteosynthesis significantly increased
both 30-day and 90-day MT.
Conclusions: In this study SD >12 h and SD >24 h
significantly increased adjusted risk of MT at
day 30 and day 90, respectively. The
adjusted risk of both 30-day MT and 90-day
mortality increased significantly when SE
was “below attending”. The study findings
challenge the departments to facilitate fast
surgical treatment supported by attending
orthopaedic surgeons.
91. Surgical delay and early mortality in patients with distal femoral fractures
Bozo Jian, Thomas Kallemose, Henrik Palm, Michael Brix, Anders Troelsen, Kirill Gromov
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: While fast surgical treatment of proximal
femoral fractures is supported by previous
studies and is encouraged by national
clinical guideline in several countries, no
consensus exists on optimal timing for
surgical treatment of the equally frail patient
group with distal femoral fractures.
Purpose / Aim of Study: The purpose of this study was to investigate
whether increased surgical delay (SD) in
patients with distal femoral fractures is
associated with risk for early mortality.
Materials and Methods: 189 patients surgically treated for distal
femoral fractures in 2008-2013 were
identified at two university hospitals.
Only patients > 50 years old were
included for analysis (n=170). Recorded
parameters included age, gender,
American Society of Anesthesiologists
(ASA) score, AO diagnosis,
osteosynthesis type, presence of total
knee arthroplasty (TKA) and SD (hours).
SD was defined as time from admission
to the hospital to beginning of surgery
and divided into groups: <12h, <24h,
<48h, <96h and >96h. 30 and 90 day
mortality was recorded. Multiple logistical
regression analysis was performed to
calculate adjusted risk for 30-day and
90-day mortality.
Findings / Results: Median age was 78, range (51-99). 80%
were female, 96% were treated with plate
fixation and 21% had a TKA at the fracture
site. 7% were operated within 12 hours,
37% within 24 hours, 62% within 48 hours
and 86% within 96 hours. 30- and 90-day
mortality rate was 5% and 11%,
respectively. Patients with surgical delay >
24 hours had a significantly increased 90-
day mortality risk (OR 5.76; p=0.03)
Conclusions: Delay of surgery > 24 hours for patients
with distal femoral fractures is associated
with increased risk for early mortality. This
should be taken into consideration when
planning surgery for this group of patients.
92. RSA-measured rotation across SHS-treated trochanteric fractures - is the anti-rotation screw obsolete?
Maiken Stilling, Torben Bæk-Hansen, Bøvling Søren, Steffen Jacobsen, Kim Holck, Henrik Palm
Department of Orhopaedics, Regional Hospital Holstebro, Hospital Unit West
Background: Rotation across trochanteric fractures
treated by a sliding hip screw (SHS)
remains controversial, and
measurement is difficult. Some
surgeons add a so-called anti-rotation
screw, but the indication is
questionable.
Purpose / Aim of Study: To investigate the amount of, and
possible predictors for, rotation across
SHS-treated stabile trochanteric
fractures by use of RSA.
Materials and Methods: 24 patients (21 female) at mean age
76 (56-91) years with SHS-treated
stabile trochanteric fractures were
followed postop, 1.5, 3 and 6 months
after surgery with marker-based RSA
and measurement of fracture migration
between the femoral head/neck and
the trochanter/shaft fragment. EGS-
RSA was used to transfer the rotation
axis in line with the sliding screw.
Screw position within the femoral head
was assessed into thirds as
high/central/low in AP and
posterior/central/anterior in LA post-
operative radiographs.
Findings / Results: No cut-outs or revisions were
observed. Average rotation across the
fracture around the sliding screw was
0.6 (sd 7.1) degrees, and rotation
stopped at 6 weeks (p>0.24). 7
patients with non-central screw
position (3 with a low AP screw
position, 4 with an LA anterior or
posterior screw position) had higher
rotation compared with 17 patients with
central screw placement in two planes
(mean 5.3 (sd 4.5) vs. 1.5 (sd 7.1)
degrees, p=0.01). Low positioned
screws with mean rotation of 8.8 (sd
3.8) degrees had the most rotation
(p=0.02). Other translations and
rotations were not correlated with
screw position.
Conclusions: Overall rotation across the trochanteric
fracture was small, but depended on
SHS position, with most rotation
following a low-positioned screw. If the
SHS is correctly positioned in the
central third of the femoral head in
both AP and LA radiographs, adding
an anti-rotation screw appears
obsolete.
93. Patient safe pain management of acute hip fracture patients requires focus on the kidney function
Morten Baltzer Andersen, Beata Malmqvist, Henrik Palm
Department of Orthopaedic Surgery & The Hospital Pharmacy, Copenhagen University Hospital Hvidovre, Denmark; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Denmark
Background: Standard medical treatment including
painkillers are often used for hip fracture
patients in Denmark. Painkillers and the
frequent co-morbidity Chronic Kidney
Disease (CKD) are a known as risk factors
for the serious complication including Acute
Kidney Injury (AKI). AKI are often reversible
but increase mortality and hospitalization.
Purpose / Aim of Study: The purpose was to identify the amount of
CKD, AKI and use of painkillers among hip
fracture patients.
Materials and Methods: 202 consecutive hip fracture patients
(71% female, mean age 78 (range 22-
97)) admitted through the ER from Sept
2012 to March 2013 were included.
Painkillers were defined as NSAID and/or
Morphine, both included in our standard
medicine package. The patient’s upper
and lower estimated Glomerular Filtration
Rate (eGFR) was recorded between
admission and discharge. The stage of
CKD was based on the patients' highest
eGFR during hospitalization and the AKI
definition was based on the eGFR
change by the RIFLE (R-risk, I-Injury, F-
failure, L-loss, E-end stage)
classification.
Findings / Results: 91 (45%) patients had a normal kidney
function, while it was reduced mildly in 69
(34%), moderately in 38 (20%), severe in 3
(1%) and a single patient had terminal renal
insufficiency. AKI occurred in 20 cases
(10%) and patients with reduced kidney
function had four times greater risk of
developing AKI (p=0.02). Among these
cases, use of NSAID was not stopped in 8
and oral Morphine in 7 of the 20 patients
after they had developed AKI.
Conclusions: Use of standardized prescribed painkillers
appear secure for 90% of hip fracture
patients. However, as half of the patients
have reduced kidney function and thereby
increased risk of AKI, continued focus on
kidney function seems necessary for
increasing patient safety.
94. Complications and Functional Outcome after Locking Plate Fixation of Distal Tibial Fractures in the Region of Southern Denmark 2007-2011
Silje Kleven, Ellen Hamborg Petersen, Bjarke Viberg, Ole Skov
Dept. of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: Distal tibia fractures often present a
challenge for the orthopaedic surgeon and
the best treatment remains controversial.
Previous research on locking plates has
shown promising results, but we do not
know enough about complications and
functional outcome
Purpose / Aim of Study: To assess the rate of complication and the
long-term functional outcome in patients with
distal tibial fractures treated with a low-
profile locking plate
Materials and Methods: A historical case-series of 70 patients
with 71 distal tibial fractures treated with
low-profile locking plate between
January 2007 and April 2011 was
retrieved. Patient-, injury- and treatment
characteristics as well as information of
post-operative complications were
retrieved from electronic health records
and patient interviews. Complications
were classified as minor complications
and major complications. Long-term
functional outcome was assessed by
EQ5D-5L, AOFAS score, and return to
pre-injury job function through patient
interview and examination
Findings / Results: There were 32 43A, 5 43B and 34 43C-
fractures, 12 open and 10 high-energy
fractures. 49 cases (69%) experienced
complications during the follow-up time, of
which 34 were minor and 15 were major
complications. The median (IQR) EQ5D-5L
index was 0.76 (0.65-0.84), health VAS-
score 80 (60-90), and AOFAS score 73 (60-
87). Logistic regression analyses showed
that smoking increased the risk of minor
complications (OR 23, p<0.018). All other
variables showed no statistical significance
for minor or major complications. 33 % of
working patients had not returned to work
as a result of the fracture
Conclusions: Our study suggests that treatment of distal
tibial fractures with low-profile locking plates
might have higher rates of complications and
worse functional outcome than previously
reported
95. A review of deep wound infection after hip-fracture surgery
Frederik Stensbirk, Henrik Palm
Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Deep wound infection is one the most
severe and costly complications following
hip-fracture surgery. The few previously
published series have shown multiple re-
operations, longer hospitalization,
massive antibiotic treatment and
increased mortality and morbidity. For
improving results, surgeons should
besides performing surgical debridement
be aware, which organisms are
responsible, the relevant antibiotics, and
the consequences for patient and
hospital.
Purpose / Aim of Study: To investigate rate, bacteriology and
antibiotic treatment of patients developing
deep wound infection following hip-fracture
surgery.
Materials and Methods: 4189 consecutive hip fracture patients
admitted and treated at our hospital from
September 2002 to June 2013 were
included. All patients were treated with
arthroplasty, intramedullary nailing, dynamic
hip screw or parallel screws/pins.
Retrospectively, deep wound infections,
bacteriology, antibiotic treatment,
hospitalization, number of re-operations and
1-year mortality were investigated.
Findings / Results: 73 patients reoperated due to deep wound
infection were identified (1.7%). 80 positive
bacterial cultures were identified. 45
displayed S. aureus (63%), 13 coag. neg.
staph. (18%), 7 E. coli (10%), 15 distributed
on 10 other bacteria, while 6 patients had
negative bacteria cultures (8%). 17 cultures
were resistant to cefuroxime (21%). 29
patients were treated with >3 antibiotics
(40%). Hospitalization was 52 days. 37
patients were re-operated more than once
(51%). Within the first year after re-
operation 30 patients had died (41%).
Conclusions: A deep wound infection rate at 1.7% is
relatively low and comparable to previously
published series, but when it occurs,
consequences are devastating. Continuous
focus on infection registration and optimal
prophylactics and treatment is therefore
important to improve outcome.
96. Nailing of unstable trochanteric fractures with and without circumferential wires – a study with focus on complications and reoperations within two years.
Lasse Birkelund, Michael Brix, Ilija Ban, Henrik Palm, Anders Troelsen
Ortopædkirurgisk, Aabenraa Sygehus
Background: Open reduction and circumferential
wires have long been controversial in
trochanteric fractures treated with an
intramedullary nail (IMN) because of
concerns about compromising the
periosteal blood supply leading to bone
necrosis. We hypothesize that wires
may instead facilitate optimal implant
position and fracture reduction
Purpose / Aim of Study: To compare per- and postoperative
results in patients with an unstable
trochanteric fracture treated with IMN
with or without wires, within 2 year
from surgery
Materials and Methods: 51 consecutive patients with
trochanteric fractures treated with IMN
and wires were identified in from two
prospective databases. It was
compared to, a by age and fracture
subtype, matched control group of 51
patients treated with IMN without wires,
selected in a third database. ASA,
operation-time, bleeding, fracture
reduction postoperative, tip-apex
distance (TAD) and reoperations within
two years were assessed from records
and radiographs
Findings / Results: Due to the match method, the 2 groups
were alike regarding age and fracture
classification. ASA and TAD was NS.
Application of wires resulted in
significantly longer operation time
(p<0.001) and increased bleeding
(p<0.001), but a superior reduction
(p<0.001). 4/51 patients with wires
were reoperated: 1 due to technical
failure during osteosynthesis, 1 screw
cut out, 1 new fracture after a fall and 1
hardware removal. 9/51 patients without
wires were reoperated: 2 deep
infections, 3 new fractures after a fall, 1
screw cut out, 1 nail removal and 2 non-
unions
Conclusions: It appears that open reduction and
application of circumferential wires
facilitates a superior fracture reduction,
probably worth the increased bleeding
and longer operation time. Future level-1
studies are warranted including outcome
parameters such as mobilization and
pain on short and longer term