Session 11: Trauma 2
Fredag den 25. oktober
09:00 – 10:30
lokale: Helsinki/Oslo
Chairmen: Michael Brix / Juozas Petruskevicius
105. Level of supervision in fracture-related surgery in Denmark. Experience from centres participating in the DFDB (Danish Fracture Database) collaboration.
Morten Jon Andersen, Kirill Gromov, Michael Brix, Anders Troelsen, DFDB Collaborators
Orthopaedics, Hvidovre Hospital
Background: The surgeon's level of experience and degree of supervision is an
important factor in outcome following fracture-related surgery. No
studies exist describing levels of supervision for fracture-related
surgery in Denmark. The Danish Fracture Database (DFDB) was
introduced as a quality-monitoring tool of fracture-related surgery
and can be used to monitor the surgeon's experience level and
degree of supervision at the participating centres.
Purpose / Aim of Study: To describe the levels of experience of the
operating surgeons and the level of
supervision for fracture-related surgeries
performed at 8 participating centres.
Materials and Methods: Currently 9.765 surgical procedures are
registered in DFDB. Data regarding
experience level of the surgeon and the level
of supervision was assessed for primary
surgeries (n=7.958) and reoperations
(n=576) separately. We describe the level of
surgical expertise and amount of supervision
for the most common fracture-related
surgeries and the most frequently re-
operated fracture types. We also investigate
the changes in supervision outside regular
working hours.
Findings / Results: Interns (IN) performed 18% and junior
registrars (JR) 29% of all primary fracture-
related procedures.
9,6% of primary procedures performed by IN
and 32% by JR, were unsupervised. IN and
JR combined operated 16% of all proximal
femoral fractures (the most frequent
fracture group reported to DFDB)
unsupervised. Unsupervised surgeries
performed by JR increased from 29,7% to
39,6% outside regular work hours
(p<0.001).
Conclusions: While overall levels of supervision were
generally high, we found that 1/3 of
procedures performed by JR were
unsupervised. Lower degree of supervision
for surgeries performed outside regular
work hours could be a matter of concern.
106. Routine blood tests indicate increased mortality risk in lower limb amputation patients
Steen Vigh Buch, Nikolaj Sode, Troels Riis, Søren Kring, Annette Sylvest, Benn Rønnow Duus
Orthopedic, Bispebjerg
Background: Non-traumatic lower limb amputation is
associated with high mortality rates.
Recent studies show mortality rates
after 30 days of 50% for through knee
amputation (TKA) and 31-36% for above
knee amputation (AKA).
Purpose / Aim of Study: The aim of this study is to review the
outcome of patients undergoing a
primary TKA or AKA and identify factors
predicting increased mortality rates.
Materials and Methods: All patients who underwent a primary
TKA or AKA at Bispebjerg Hospital,
Copenhagen in the period from February
2009 to February 2013 where identified
using the hospital surgery database
(Orbit).
Patient records were reviewed
retrospectively and additional data was
obtained from the hospital biochemistry
department and the national civil register.
154 patients (82 male, 72 female) with
69 TKA and 85 AKA were identified.
Mean age for patients was 74.0 years.
P<0.05 was considered significant.
Findings / Results: The mortality rates after 30 days (D30)
were 14.5% for TKA and 23.5% for
AKA, and after 90 days (D90) 36.2% for
TKA and 40.0% for AKA.
Comparison of mortality rates revealed
that male versus female patients had a
higher risk of D30 (OR 2.41, p<0.04)
with no significant difference for D90
(OR 1.67, p<0.1). No further significant
differences were identified.
Regarding blood samples, serum
creatinine (>100 ìmol/L), leucocytosis
(>15.1 x 10-9/L) and CRP (>50 mg/L)
were associated with significantly
higher D90 (OR 3.27, p<0.001, OR 2.69,
p<0.009 and OR 3.37, p<0.006,
respectively).
Conclusions: In this study, mortality rates are in line
with comparable studies. Male patients
tend to have higher mortality rates
postoperatively, though data is not
conclusive.
Leucocytosis, elevated levels of both
serum creatinine and CRP correlate to
increased risk of death postoperatively,
and could help identify the group of
patients in need of special attention.
107. High patient volume is associated with increased 30-day mortality after hip fracture.
Pia Kjær Kristensen, Theis Muncholm Thillemann, Søren Paaske Johnsen
Orthopaedic Surgery, Region Hospital Horsens; Ortopaedic Surgery, Region Hospital Horsens; Clinical Epidemiology, Aarhus University Hospital
Background: Hip fractures are associated with
increased mortality. Arthroplasty
procedures have demonstrated better
clinical outcomes at high volume units,
but the results after hip fracture are
inconclusive.
Purpose / Aim of Study: We aimed to evaluate the association
between patient volume in hip fracture
units and 30-day mortality.
Materials and Methods: Using prospectively collected data from
the Danish Hip Fracture Registry, we
identified 12,065 patients ≥ 65 years
that were admitted with a hip fracture
from 2010 to 2011. Patient volume was
divided in three groups (≤170 hip
fracture admissions per year, 171 to 350
and ≥351 admissions per year). The
primary outcome was 30-day mortality.
Secondary outcome included quality of
care assessed using six process
indicators. Data was analyzed using
regression techniques while controlling
for potential confounders.
Findings / Results: The 30-day mortality was 10.5%, 11.0%
and 13.2% for low, medium and high
volume units, respectively. Admittance
to high volume units was associated with
higher 30-day mortality (adjusted odds
ratio (OR) = 1.26, 95%CI: 1.01-1.58).
Furthermore, patients who were admitted
to high volume hip fracture units had
lower odds for being mobilized within 24
hours postoperatively (OR=0.71, 95%CI:
0.61-0.82), for basic mobility
assessment (OR=0.60, 95%CI: 0.50-0.73),
and for receiving a post discharge
rehabilitation program (OR=0.48, 95%CI:
0.38-0.60). After adjusting for
different quality of care, mortality was
comparable (OR=1.14, 95%CI: 0.81-1.60).
Conclusions: Patients with hip fractures admitted to
high volume units have higher mortality
rates and receive lower quality of care.
Variations in quality of care could
apparently explain variations in 30-day
mortality between units with low and
high patient volume.
108. External versus internal fixation of intra-articular distal tibial fractures - A systematic critical review
Peter Ivan Andersen, Bjarke Løvbjerg Viberg, Morten Schultz Larsen
Ortopædkirurgisk afdeling, Kolding Sygehus, SLB
Background: Intra-articular fractures of the distal tibia
are among the most challenging of
orthopaedic problems.
The management of these fractures
requires both an understanding of the
delicacy of the soft tissue on the distal
1/3 of the tibia, comprehension of the
current concepts of treatment and the
expertise to apply this knowledge into
the treatment of these fractures
Purpose / Aim of Study: The aim of this review was to evaluate
literature comparing external fixation
(EF) to open reduction and internal
fixation (ORIF) of intra-articular distal
tibial fractures with focus on
complications and functional outcome
Materials and Methods: A search string was designed to search
Pubmed, Embase and Cochrane
Databases for the literature and
revealed 13,096 articles (1993 dublets).
2 reviewers independently assessed
the literature for relevance by title,
abstracts and full text. Initially only level
2 evidence and above was accepted
which gave 3 articles, and therefore
level 3 evidence was included and gave
2 more articles. Extraction of data were
done by 2 reviewers and sorted
regarding to study aims. The quality of
studies was assessed by both
reviewers using CASP 2010 checklists
Findings / Results: The 5 articles covered 258 intra-articular
distal tibia fractures, 118 managed by EF
and 140 treated by ORIF. The patients
treated with EF are more often subject to
non-union, mal-union, and deep infection
than patients with ORIF. Very few
studies include good functional scores
but there might be a better functional
outcome after 6 months which even
outs after 1 year
Conclusions: The literature at hand is still insufficient
to make any definitive conclusions.
There is not yet an agreement of which
clinical scores to use in follow up, and
the low level of evidence in study design
makes confounding bias a great risk
109. Over- og undertriage ved modtagelse af multitraumatiserede patienter - En sammenligning af to triagesystemer
Torben Stryhn, Morten Schultz Larsen
Ortopædkirurgisk afdeling, OUH
Background: Correct trauma team activation (TTA) is
important. Undertriage may affect
mortality, but overtriage is resource
consuming and may affect awareness of
the Trama Team
Purpose / Aim of Study: This study was done to evaluate the
difference between two triage systems
used by Odense University Hospital in
the period 1/6-31/12; 2010 and 2011.
Especially the ability to correctly
identify the multitraume patient defined
as ISS > 15
Materials and Methods: A score system based on basic
observations were used in the first
period 1/6 – 31/12 2010. In the second
period a more clinically oriented system
based on evaluation by trained health
proffesionals were used. A
retrospective comparative cohordstudie
using UAG's trauma registry, and medical
record review. For each period two
groups was identified. 1) Patients
received in the emergency room by TTA.
Exclusion: Patients transferred from
other hospitals. 2) All other admissions
with the trauma codes T or S was
reviewed. Deaths within 30 days after
emergency room contact, was evaluated
separately without any possibility of
exclusion. Exclusion criteria: Isolated
hip fracture or hospital admissions
shorter then 3 days.
Findings / Results: In 2010 and 2011, 614 and 451 patients
was received by TTA, 565 and 503 was
admitted without. The groups were
statistically homogeneous. Overtriage
was reduced from 47% to 39%, undertriage
from 7% to 6%. The reduction in
overtriage was statistically
significant. A substantial amount of
undertriaged patients had severe head trauma
Conclusions: The introduction of a new triagesystem,
with emphasis on the clinical assessment
by trained health professionals, has
resulted in a reduction of overtriage,
without increasing the undertriage. The
results are in accordance, with
international recommendations and
previous Scandinavian studies.
110. Patient volume in hip fracture units is associated with increased length of hospital stay and increased surgical delay.
Pia Kjær Kristensen, Theis Muncholm Thillemann, Søren Paaske Johnsen
Orthopaedic Surgery, Region Hospital Horsens; Ortopaedic Surgery, Region Hospital Horsens; Clinical Epidemiology, Aarhus University Hospital
Background: Hip fractures are associated with the
largest use of bed days in hospitals in
the Western World. It is unclear whether
there are any scale advantages from
treating a larger number of patients
with hip fractures.
Purpose / Aim of Study: We examined on patient level whether
patient volume in hip fracture units is
associated with length of hospital stay
and surgical delay.
Materials and Methods: In a nationwide prospective
population-based cohort study, we
identified 12,065 Danish patients aged
>65 years with an incident episode of
hip fracture admitted between 2010 to
2011. The patient volume was divided in
three groups (≤170 hip fracture
admissions per year, 171 to 350 and ≥351
admissions per year). The primary
outcome was length of hospital stay.
Secondary outcome included surgical
delay. Data was analyzed using
regression techniques while controlling
for potential confounders.
Findings / Results: Length of hospital stay was 7.9 days,
8.1 days and 10.7 days for low, medium
and high volume units, respectively.
Admittance to high volume units was
associated with a longer length of
hospital stay (adjusted OR 1.29, 95%CI:
1.07-1.55 ). Surgical delay was 20.4
hours, 21.8 hours and 23.0 hours for
low, medium and high volume units,
respectively. Admittance to high volume
hospital was associated with a longer
surgical delay (adjusted OR 1.27, 95%CI:
1.02-1.57).
Conclusions: Patients with hip fractures admitted to
high volume units have increased
surgical delay and increased length of
hospital stay compared to low volume units.
111. Demographic and short-term outcome changes within 10 years of a multimodal fast-track hip fracture program
Morten Tange Kristensen, Henrik Palm
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy and , Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Hip fracture rates seem to have fallen
within the last decade but whether
patient demographics and short-term
outcome also changed during this
period is unknown.
Purpose / Aim of Study: To examine changes within a 10 year
period in patient demographics,
fracture type distribution, and outcome
among patients admitted to a
specialized hip fracture unit at a
university hospital.
Materials and Methods: A consecutive series of 288 patients,
median (IQR) age of 83 (77-88) years,
admitted within 6 months of 2012 was
compared with 288 patients, median
age of 81 (73-87) years, admitted at
the same hospital from September
2002, and with respectively 82% and
81% admitted from their own home.
The pre-fracture functional level was
evaluated with the New Mobility Score
(NMS, 0-9 points).
Findings / Results: The percentage of men admitted with a
hip fracture increased to 35%
(101/288) in 2012, from 26 % (76/288)
in the 2002 cohort (P=0.02), while no
significant difference was seen over
time for age, type of fracture, and
cognitive status. Patients however had
a higher pre-fracture functional level
(median NMS, IQR) from 4 (3-9) in
2002 versus 6 (3-9) in 2012 (P=0.01).
Time in hospital was unchanged, with
a 2012 median LOS of 11 (7-16)
versus 11 (6-23) in 2002, and
corresponding with 79% and 77%
discharged directly to their previous
residence. Patients not discharged
directly to their own home were more
often referred to rehabilitation in 2012
as compared to nursing home in 2002
(P<0.001).
Conclusions: The rate of men sustaining a hip
fracture increased significantly with 9%
from 2002 to 2012 at our institution,
while the pre-fracture function in
general was improved. Whether this
increase is representative for other
parts of Europe, should be further
examined. Also, more details of the
male cohort should be examined for
prophylactic treatment of risk patients.
112. Venous thrombosis following fractures below the knee, a nationwide cohort study
Liv Riisager Wahlsten, Henrik Eckardt, Gunnar Hilmar Gislason, Jonas Bjerring Olesen, Christian Torp-Pedersen
Orthopedic, Rigshospitalet; Cardiology, Gentofte ; Institute of Healt, Science and Technology, Aalborg
Background: Only few studies have investigated the
risk of deep venous thrombosis (DVT)
or pulmonary embolism (PE) after
osteosynthesis of fractures below the
knee. Antithrombotic treatment
following discharge is currently not
recommended in international literature.
Purpose / Aim of Study: The aim of this study was to
investigate the incidence of clinical
significant DVT/PE in patients
undergoing osteosynthesis of fractures
below the knee, and to identify specific
risk factors associated with the event.
Materials and Methods: Using individual linkage of nationwide
registries, we included all patients
undergoing osteosynthesis below the
knee, 1999-2011. Event rates of
DVT/PE were calculated and
significant risk factors were identified
using cox regression analyses.
Patients were followed 180 days from
discharge.
Findings / Results: We included 37,853 patients, from
these 314 (0.8%) had DVT/PE that
demanded hospitalization within 180
days. The event rate was markedly
increased the first weeks after
discharge, and decreased with time,
stabilizing 12-14 weeks after
discharge. Oral anticonceptives
(Hazard Ratio [HR] 3.58), former
DVT/PE (HR 6.XX), and peripheral
artery disease (HR 3.1X) were the risk
factors associated with the highest
incidence of postoperative DVT/PE.
Also obesity was associated with an
increased risk of DVT/PE.
Conclusions: The overall risk of DVT/PE after
osteosynthesis of fractures below the
knee was lower than the risk of
DVT/PE after hip or knee replacement.
However, the risk of DVT/PE in
patients with one or more of the risk
factors identified above is similar or
higher than the risk of DVT/PE after
hip and knee replacement, and our
study thus suggest that these patients
could benefit from the prolonged
anticoagulation therapy after
discharge.
113. The management of anticoagulant therapy in hip fracture patients in Denmark
Peter Toft Tengberg, Nicolai Bang Foss, Henrik Palm, Anders Troelsen
Ortopædkirurgisk afd. 333, Hvidovre Hospital; Anæstesiologisk afd. , Hvidovre Hospital
Background: There is no consensus in the literature
regarding the management of hip fracture
patients who are receiving oral anticoagulant
therapy on admission. The concept of
cessation of treatment to prevent increased
blood loss during operation is currently being
debated in the literature. Recent studies
suggest that this practice results in
unnecessary delay of surgery, and
increased risk of thromboembolic events.
Purpose / Aim of Study: We investigated current practice in the
management of hip fracture patients in oral
anticoagulant therapy in Denmark and
compared the current practice with the latest
findings in the literature.
Materials and Methods: We made a web based survey of the
current practice concerning patients in oral
anticoagulant therapy in 24 Danish
orthopedic departments treating hip
fractures. Contact was made by e-mail to
the head of the traumatology team. We made
a systematic search of the literature on the
field in PubMed.
Findings / Results: We found that there was some discrepancy
in the management of these patients in
Danish orthopedic departments. Some
departments do not have a clinical guideline
on the subject, but rely on the guidance of
other departments in the management of
these patients. Some departments delay
surgery in order to manage the risk of blood
loss. Other departments have a more
aggressive approach with no delay in
surgery. We found that the literature on this
field is very limited and characterized by low
level of evidence.
Conclusions: The management of hip fracture patients
who are receiving oral anticoagulants on
admission shows markedly variance
between centers in Denmark. This could in
part be explained by the small amount and
low level of evidence of studies on this
subject. Studies investigating the
controversies of the existing, “surgery-
postponing” management are warranted.
114. Reliability of a Scoring System for Measurement of Implant Position after Internal Fixation of Undisplaced Femoral Neck Fractures
Marie-Louise Lervad Bartholin, Kolja Weber, Rune Dueholm Bech, Henrik Palm, Bjarke Viberg, Morten Schultz Larsen
Orthopedic Surgery and Traumatology, Odense University Hospital; Orthopaedic Surgery,, Hvidovre University Hospital; Orthopaedic Surgery, Hvidovre University Hospital,
Background: Implant position may be an important
predictor of failure after internal
fixation (IF) of undisplaced femoral
neck fractures (uFNF), but the use of
scoring systems for measurement of
implant position have been somewhat
unreliable in previous studies.
Purpose / Aim of Study: The aim of this study was to evaluate
the reliability of a scoring system for
measurement of implant positioning after
IF of uFNF.
Materials and Methods: 102 patients admitted with an uFNF
treated with IF at one hospital between
01.05.2005 and 02.04.2007 were
retrospectively included. Implant
position on the first postoperative
anterior-posterior and axial radiographs
were both assessed visually and
objectively measured according to a
scoring system including screw tip
distance, screw-shaft angle,
screw-calcar distance, and screw
positioning in the femoral head. Three
raters (one medical student and two
residents) each made the assessments
twice with minimum 14 days interval,
blinded for each other’s results. An
independent person performed unweighted
kappa statistics.
Findings / Results: Visually assessed implant position gave
intra-rater kappa results at 0.40-0.75
(rater 1), 0.75-0.98 (rater 2) and
0.69-0.81 (rater 3), with inter-rater
kappa results at 0.18-0.80 (combined
range). Objectively measured implant
position gave intra-rater kappa results
at 0.56-0.88 (rater 1), 0.74-0.87 (rater
2) and 0.81-0.94 (rater 3), with
inter-rater kappa results at 0.48-0.85
(combined range).
Conclusions: Implant position simply assessed
visually confirmed to be unreliable but
this appeared improvable by objectively
measurement. Thus, measurements should
be studied for relevance in future
formal scoring systems for predicting
failure after surgery.
115. Reoperation rates on proximal femoral fractures
Pernille Nygaard Vedel, Troels Riis, Annette Sylvest, Henrik Løvendahl Jørgensen, Benn Duus
Department of Orthopedic Surgery, Bispebjerg; Departement of Clinical Biochemistry, Bispebjerg
Background: Reoperation rates on patients with
proximal femoral fractures (PFF) are
reported to be between 5-20%. This
depends on the pattern of fracture.
However, other factors including
surgical experience and choice of
implants have been shown to influence
the reoperation rate as well.
Purpose / Aim of Study: To study the association of reoperation
rate among PFF at Bispebjerg Hospital
with fracture type, surgical experience
and type of implant.
Materials and Methods: A retrospective evaluation of 459
patients with operated PFF in a one-year
consecutive period (01.09.2011 -
31.08.2012) with 6 months
postoperative follow up.
Fractures were stratified as Garden I-II,
III-IV femoral neck fractures or
extracapsular fractures.
Surgeons were grouped as residents,
senior residents or specialist.
Following implants were registered;
parallel screws, four-hole sliding hip
screw, intramedullary nail and
hemiprosthesis.
Findings / Results: Overall 8,7% underwent reoperation
within 6 months.
15,1% of Garden I-II, 17,3% of Garden III-
IV and 3,0% of the extracapsular
fractures were reoperated.
Multivariate Cox regression analysis
incorporating fracture type, type of
surgery and surgical experience,
showed no significant influence of
variance in surgical experience (p=0.8)
or type of fracture (p=1), but significant
difference in frequency of reoperation
related to type of surgery (p=0.02).
Parallel screws had the highest
reoperation rate at 18,9%.
For parallel screws in Garden III-IV
fractures the reoperation rate was
26,9%, for hemiprosthesis it was 15,1%.
Conclusions: The reoperation rate for femoral neck
fractures is higher than for
extracapsular fractures.
The Garden III – IV treated with parallel
screws had the highest reoperation rate
(26,9%) compared to 15.1% for those
treated with hemiprosthesis and 15.1%
for the Garden I – II treated with parallel
screws.