Session 2: Traume I
Ondag den 21. oktober
09:00 – 10:30
Lokale: Stockholm/Copenhagen
Chairmen: Ilija Ban / Bjarke Viberg
13. Treatment Of Displaced Femoral Neck Fractures With An Uncemented Hemiarthroplasty (Corail, DePuy). A Series Of 318 Consecutive Fractures, With Focus On Major Complications.
Ciea Grønlund, Thomas Sandholdt Andreasen, Line Hernæs Husby, Morten Schultz Larsen, Michael Brix
Ortopædkirurgisk Afdeling O, University Hospital of Odense
Background: Hemiarthroplasty is the preferred
treatment for displaced femoral neck
fractures (DFNF) in elderly patients
(>70 years). The use of uncemented stems
remains controversial. Few studies
report data about the setting in which
the results is achieved.
Purpose / Aim of Study: Our outcome is overall reoperation rate
and the rate of major complications;
deep infections, periprosthetic
fractures, dislocations, hip pain or
loosening of the implant. We describe
the setting in which the results have
been achieved, and whether surgical
treatment was according to the standard
treatment algorithm for the department.
Materials and Methods: A retrospective study including all
consecutive patients who had sustained
DFNF and had been operated with an
uncemented hydroxyapatite coated
hemiarthroplasty (Corail, Depuy) from
2009-1-1 to 2012-31-12 at OUH. Patients
were identified using the nationwide
patient record system. Data was
extracted from patient records. X-rays
were examined by a younger doctor and a
senior consultant.
Findings / Results: 318 patients, median age 83 years.
Standard treatment algorithm was
followed in all cases. A minor fracture
occurred during surgery in 6 cases. 1
patient died within 48 hours after
surgery.
The rate of complications
leading to reoperation was: Dislocation;
3,1%, deep infection; 2,2%,
periprosthetic fracture; 5,0%, hip pain;
0,9%, stem loosening; 0%.
Reoperation rate didn’t differed even
though more than 90 surgeons performed
the surgeries, 213 by younger doctors,
105 by an attendant or above.
Conclusions: We find reoperation rates acceptable and
comparable to other studies. Stem
loosening seems to be non-existing. It
seems safe that the surgeries are
performed by younger doctors under
supervision. Forward focus should not
only be on cemented vs. uncemented
stems, but also on the setting in which
the surgeries are being performed.
14. Results of tibial nailing with angular stable locking screws (ASLS)
David Lunde Hatfield, Mohammed Sherif, Peter Kraglund, Morten Schultz Larsen, Michael Brix
Dept. of Orthopaedics and Traumatology, Odense University Hospital, Syddansk Universitet; Orthopaedic surgery, Odense University Hospital, Denmark
Background: Current standard treatment of tibia fractures
involves a high rate of unwanted
complications and non-unions. Therapy with
ASLS is introduced later and is now widely
used in Denmark. At present time there is
little published clinical clinical data in the
relevant literature. Several biomechanical
studies have been carried out showing
positive results and capacities of the ASLS.
Purpose / Aim of Study: The aim of the study was to present early
and mid-term clinical results of
intramedullary nailing combined with
angular stable locking system (ASLS) in
distal and diaphyseal tibial fractures. The
study was done with these following core
parameters: Time to healing, union rate,
secondary loss of reduction as well as rate
and causes of reoperation
Materials and Methods: A consecutive series of 107 patients with
distal tibialfractures were treated with
Synthes Expert Tibial Nail combined with
ASLS between September 2009 and June
2014. All fracture types AO42 and AO43
were included except AO43 B2,B3 and C3.
One patient was lost to follow up. The
patients were followed up postoperatively
with radiographs and clinical control every 6
weeks until healing.
Findings / Results: We found a union rate of 100% with an
average of 5,1 months to healing and a low
rate of complications. In particular, a low
rate of infection (one patient) was found.
No patients had non-union. 37 patients were
re-operated; 34 patients because of
hardware removal and three patients
because of major complications.
Conclusions: Intramedullary nailing combined with ASLS
in distal tibial fracture provides a high rate of
union and low rate of major complications.
This suggests that the treatment is safe and
capable of achieving favourable clinical
results.
15. Interrater reliability, agreement and internal consistency of Constant score in patients with clavicle fractures
Ilija Ban, Anders Troelsen, Morten Tange Kristensen
Orthopaedics and Clinical Orthopaedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research –Copenhagen (PMR-C), Dept. of Physiotherapy, Copenhagen University Hospital Hvidovre
Background: Despite being a frequent injury, the optimal treatment
of clavicle fractures is still debatable. Constant score
(CS, 0-100 points) has been the primary endpoint in
all recent randomized studies concerning clavicle
fractures. However, CS was not developed to asses
patients with clavicle fractures and the psychometric
properties (reliability, validity and responsiveness)
have not been evaluated on these patients
Purpose / Aim of Study: To examine the interrater reliability, agreement and
internal consistency of the Danish version of CS on
patients with a clavicle fracture
Materials and Methods: Based on sample size, 34 patients (29 males, mean
age 41.3 years) with clavicle fractures (2 medial, 21
midshaft and 11 lateral) had standardized CS
assessment done by two independent and
experienced raters, 5-8 weeks following injury.
Interrater reliability and agreement of the overall CS
was determined . The interclass correlation
coefficient (ICC2.1), standard error of measurement
(SEM), minimal detectable change (MDC) and
Cronbach´s Alpha coefficient were used to evaluate
data
Findings / Results: The interrater reliability of the total CS in patients with
clavicle fractures was excellent (ICC=0.94; 95%CI
0.88-0.97) and with no systematic difference
between the two raters (p=0.75). The SEM,
representing the measurement error on group level,
was 4.94, while the MDC; the smallest change
needed to indicate a real change for an individual
patient was 13.69. Internal consistency of the 10 CS
items was good as Cronbach´s Alpha was 0.85
Conclusions: The CS is a reliable tool when assessing patients
with clavicle fractures and with a small measurement
error at a group level. The responsiveness and
whether the CS results reflect the functional deficit of
patients with clavicle fractures when evaluated with
other outcome measures is still unknown
16. Reproducibility of malleolar classification systems
Jesper Stork-Hansen, Tamim Ahmad Haidari, Roland Knudsen, Rune Dueholm Bech, Bjarke Viberg
Dept. of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: Classification of malleolar fracture is
important when deciding for surgical or
conservatively treatment, and the literature
have provided several classification
systems concerning the stability of the
fracture.
Purpose / Aim of Study: To assess the reproducibility of malleolar
fracture in Lauge-Hansen (LH), AO/Weber
(AO), ankle stability assessment (SA) and
operative decision (OD) in adult patients with
primary malleolar fractures.
Materials and Methods: A historical cohort was retrieved from
the county database using ICD10
diagnoses for malleolar fractures
(DS824-DS828). The study period was
01/01/2010 to 01/08/2011 in order to
reach the calculated sample size (489).
692 patients x-ray images were
reviewed for inclusion and the final
cohort consisted of 496 malleolar
fractures. The included x-ray images
were reviewed 2 times with minimum 14
days interval by 2 medical students, 2
residents and 1 consultant in orthopaedic
traumatology. All x-ray images were
measured independently and any patient
identifiers were removed. The raters
were blinded to each other and own
results. Unweighted kappa statistics
were used to assess reproducibility.
Findings / Results: Overall mean (95 % confidence interval – CI)
interrater kappa results for the
classifications systems were 0.65
(0.64;0.68) for LH, 0.62 (0.60;0.63) for AO,
0.61 (0.57;0.62) for SA, and 0.70 (0.68;0.72)
for OD. The intrarater results ranged from a
mean kappa of 0.64-0.80 for the medical
students, 0.65-0.81 for the residents, and
0.82-0.84 for the consultant.
Conclusions: There do not seem to be any difference in
the reproducibility of any of the classification
systems, stability assessment or operative
decision.
17. Does intermittent pneumatic compression affect time to surgery for malleolar fracture patients?
Kristine Bollerup Arndt, Anders Jordy, Bjarke Viberg
The department of Orthopaedic Surgery, Lillebaelt Hospital Kolding
Background: Surgery of malleolar fractures are often
delayed due to oedema of the ankle. The
use of intermittent pneumatic
compression (IPC) is thought to reduce
oedema of the fracture site and thereby
time to surgery in patients with
internal fixated malleolar fractures.
Purpose / Aim of Study: To investigate the influence of IPC on
time from admission to surgery in adult
patients with acute primary malleolar
fractures treated with open reduction
and internal fixation.
Materials and Methods: February 1st 2013 IPC was introduced as
a standard procedure for all patients
admitted with a malleolar fracture. Data
was retrieved from the county database 2
years prior and after the introduction
date. The search was based on a
combination of ICD10 diagnoses and
procedure codes (DS826-8 and NHJ60-61).
The groups were statistically compared
using Wilcoxon signed rank test.
Findings / Results: 195 patients were included, 82 with IPC
and 113 without IPC treatment. There
were 104 female and 91 male with a
median age (interquartile range – IQR)
of 53.5 (39.7-64.5). Time to surgery was
median (IQR) 20.5 hours (7.5-41.6) with
IPC treatment and 24.6 hours (10.8-46.9)
without IPC treatment. There were no
statistically difference between the two
groups (p<0.117).
Conclusions: There does not seem to be any benefit
from IPC on time to surgery in patients
with acute primary malleolar fracture.
18. Surgical blood loss and mortality after hip fracture surgery
Lisa Lethan, Henrik Palm, Nicolai Bang Foss, Thomas Kallemose, Anders Troelsen, Peter Tengberg
Ortopædkirurgisk Afdeling, Copenhagen University Hospital Hvidovre
Background: Hip fractures and the surgery that
follows is known to cause a large blood
loss that in turn causes anaemia and the
need for transfusions. To our
knowledge it has not been established
whether surgical blood loss within the
normal range has any impact on mortality
after hip fracture surgery.
Purpose / Aim of Study: To investigate whether surgical blood
loss, total blood loss and red blood cell
transfusion has an impact on mortality.
Materials and Methods: Retrospectively review of all patients
who were admitted and subsequent
operated at our institution for an extra-
capsular fracture of the hip using a
short intramedullary nail between 1st of
January 2011 to 31st of December 2013.
Primary endpoint was mortality related to
Surgical Blood Loss (SBL). Secondary
outcomes were mortality related to Total
Blood Loss (TBL), Red Blood Cell (RBC)
transfusions and Massive transfusions
(MT).
Findings / Results: We identified 320 patients operated
using an IMN. The mean SBL for all
patients was 235 mL (20-2200 mL) and
the mean TBL was 2006 mL (213-7615
mL). A logistic regression analysis was
performed on 30-day and 90-day
mortality in relation to SBL, TBL and units
of RBC transfusions. All associations
were insignificant except for the
association between units of RBC
transfusions and increased 90-day
mortality. It showed that there was
significant increased risk of death within
90 days of 15% per transfused unit (OR
1,152, CI = 1,002:1,325, p = 0,048).
Conclusions: our study has proven no significant
relationship between greater SBL or TBL
and mortality within a normal range of
blood losses. We did find a 15 %
elevation in 90-day mortality risk for
every RBC transfusion. The study
design did not allow us to make any
conclusions whether this was a result
of the transfusion itself or from the
patient being in the physiological state of
needing a transfusion (PANT).
19. Reliability of posterior tilt in Garden I-II femoral neck fractures by eye-estimation, trabecular-angulation and a new cortex-surface method
Lotte Gerholt, Haider Karim Abd-El-Redda, Anna Gaki Lindestrand, Kasper Gosvig, Ilija Ban, Henrik Palm
Hip Fracture Unit, Department of Orthopaedic Surgery , Copenhagen University Hospital Hvidovre; Centre for Functional and Diagnostic Imaging and Research , Copenhagen University Hospital Hvidovre; Hip Fracture Unit, Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: Posterior tilt in Garden I-II femoral neck fractures is
debated as a predictor of reoperations following
osteosynthesis. We hypothesized that a new method
first published in 2009, based on angulation
measurement between the outer cortex-surfaces of
the femoral head sphere and neck cylinder, would be
more reliable than the eye-estimation or trabecular-
angulation previously used in literature.
Purpose / Aim of Study: To examine the reliability of these three different
methods.
Materials and Methods: All 51 consecutive patients with a Garden I-II femoral
neck fracture admitted to our institution in 2013 were
retrospectively included. Preoperative axial
radiographs were used to assess posterior tilt by the
three different methods. Assessments were
performed twice minimum 8 weeks apart, by 5
doctors with varying charge, given 5 radiographs of
training. Radiographs were randomly shuffled and
type of operation blinded. SPSS statistical software
was used to calculate Pearson correlation coefficient
(PCC) between methods and inter- and intraclass
correlation coefficients (ICC) between observers.
Findings / Results: The 51 assessments took mean 17 minutes (range
9-30) by use of eye-estimation, 28 min (12-50) by
trabecular-angulation and 120 (57-183) min by the
new cortex-surface method. The mean PCC for
same observer using the new cortex-surface
method versus the eye-estimation and trabecular-
angulation was 0.77 (range 0.67-0.87) and 0.76
(0.72-0.85) respectively, compared to 0.86 (0.71-
0.93) between the latter two. The mean inter- and
intra-observer ICC’s were 0.77 (range 0.66–0.85)
and 0.90 (0.78–0.95) for eye-estimation, 0.77 (0.63–
0.88) and 0.91 (0.84–0.96) for trabecular-angulation
and 0.88 (0.78–0.95) and 0.92 (0.89–0.97) for the
new cortex-surface method.
Conclusions: This new cortex-surface method is time-consuming,
but appears to be more reliable.
20. Should we bury K-wires after metacarpal and phalangeal fracture osteosynthesis?
Mads Terndrup, Thomas Giver Jensen, Søren Kring, Martin Lindberg-Larsen
Department of Orthopaedic Surgery, Bispebjerg Hospital
Background: Burying of K-wires after metacarpal
and phalangeal fracture
osteosynthesis may reduce risk of
infection, but it might also complicate
later removal.
Purpose / Aim of Study: To examine infection and reoperation
rates after metacarpal and phalangeal
fracture osteosynthesis with buried
versus exposed K-wires.
Materials and Methods: 597 metacarpal and phalangeal
fractures treated with K-wire
osteosynthesis at Bispebjerg
Hospital from 1st of January 2009 to
1st of February 2015 were identified
retrospectively. Excluded were cases
requiring simultaneous
osteosynthesis of other fractures,
Ishiguro procedures, cases with K-
wire removal in other hospitals and
cases where it could not be identified
whether K-wires were buried or not.
The final study population included
444 procedures in 331 metacarpal,
109 phalangeal and 4 mixed
fractures. In all cases surgical and
patient records ¡Ü90 days
postoperatively were examined.
Findings / Results: The K-wires were buried in 337
(75.9%) cases and exposed in 107
(24.1%). A total of 14 (4.0%) cases
with buried K-wires presented with
later superficial infection versus 7
(6,5%) in cases with exposed K-wires
(p=0.311). Overall, none of these
infections caused re-operation. In 58
cases (17.2%) buried K-wire removal
was not possible in the outpatient
clinic and required readmission for
removal in the operation theatre. All
exposed K-wires could be removed
without re-operation.
Conclusions: There was no significant difference in
postoperative infection rate between
metacarpal and phalangeal
osteosynthesis with buried versus
exposed k-wires. However, burying
lead to unplanned re-operations for K-
wire removal in 17.2% calling for
reconsideration of surgical strategies.
21. The basic mobility status at the time of acute hospital discharge is an independent risk factor for long-term mortality after hip fracture
Morten Tange Kristensen, Henrik Kehlet
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy a, Hvidovre Hospital, Copenhagen University; Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University
Background: One might ask; does it really matter if
patients with hip fracture (HF) regain
an independent ambulatory status in the
acute hospital towards reducing odds of
the ultimate fatal event after trauma,
death?
Purpose / Aim of Study: To evaluate the importance of the basic
mobility status at the time of acute
hospital discharge to 1- and 5-year
deaths after HF.
Materials and Methods: 491 patients who followed a multimodal
fast-track HF program until discharged
from an acute orthopedic ward. The
median (IQR) age was 81 (74-87) years;
133 men and 358 women; 250 cervical and
241 with a trochanteric fracture. The
national hip fracture register Cumulated
Ambulation Score (CAS 0-6 points) was
used to evaluate the basic mobility
status. A CAS=6 point equals an
independent basic mobility status.
Findings / Results: 107 (22%) patients with a CAS<6 at time
of hospital discharge stayed in the
acute ward a median of 22 (15-32) days
post-surgery as compared to a median of
11 (8-16) days for those 384 patients
who achieved a CAS=6. Overall 1-year
mortality was 15%, while it was 11% for
those with a CAS=6 and 29% for those
with a CAS<6. Corresponding data for
5-year deaths was 38% and 67%. Cox
regression analysis demonstrated that
the likelihood of not surviving the
first year after HF was 2 times higher
for those with; a CAS<6, a low
prefracture functional level, for men,
and for those with an American Society
of Anesthesiologists rating of 3-4
points, when adjusted for age and
cognitive status.
Conclusions: The regain of basic mobility
independency (CAS=6) within the primary
acute hospitalization seems highly
relevant towards reducing long-term
deaths following HF. Enhanced efforts
should therefore be instigated to
improve the basic mobility status of
patients with HF before discharge from
the acute hospital.
22. Performance measures and 30 day mortality after hip fracture in the elderly: a nationwide cohort study
Pia Kjær Kristensen, Theis Muncholm Thillemann, Kjeld Søballe, Søren Paaske Johnsen
Department of Orthopedic Surgery , Regional Hospitalet Horsens; Department of Orthopedic Surgery, University hospital Aarhus; Department of Clinical Epidemiology, Aarhus University Hospital
Background: High mortality rates after hip fracture
among elderly patients is of concern.
Unfortunately, studies concerning the
association between performances
measures and 30 day mortality are
lacking.
Purpose / Aim of Study: We therefore examined the association
between seven evidence based
performance measures including;
systematic pain assessment,
mobilization before 24 hours
postoperatively, basis mobility
assessment at admission and at
discharge, receiving a post discharge
rehabilitation program, anti-
osteoporotic medication, fall prevention
and 30 day mortality among elderly
patients with hip fracture.
Materials and Methods: Using prospectively collected data
from the Danish Multidisciplinary Hip
Fracture Registry, we identified 25,354
patients ¡Ý65 years who were admitted
with a hip fracture between March
2010 and November 2013. Each
performance measure was analyzed
separately. Furthermore we included
all performance measures in the same
regression model for their mutual
adjustment. The outcome was 30-day
mortality. For the analysis, we only
included patients found eligible for the
interventions. Data was analyzed using
regression techniques while controlling
for potential confounders.
Findings / Results: Overall, the 30-day mortality was 11.2
%. All seven interventions were
associated with lower 30 day mortality.
The adjusted mortality odds ratios
(ORs) ranged from 0.41 (95 % CI:
0.33-0.51) for post discharge
rehabilitation program to 0.61 (95% CI:
0.55-0.68) for prevention of future fall
accidents. In the mutual adjustment,
only mobilization within 24 hours
postoperatively and receiving a post
discharge rehabilitation program were
associated with lower 30 day mortality.
Conclusions: Mobilization within 24 hours
postoperatively and discharging
patients with a rehabilitation program
seems to lower the 30 day mortality
among patients with hip fracture.
23. Performance measures, length of stay and readmission 30 days after discharge among hip fracture patients: a nationwide study
Pia Kjær Kristensen, Theis Muncholm Thillemann, Kjeld Søballe, Søren Paaske Johnsen
Department of Orthopedic Surgery, Regional Hospital Horsens; Department of Clinical Epidemiology, Aarhus University Hospital
Background: Data on the association between
performance measures of hip fracture
care, length of stay (LOS) and risk of
readmission within 30 days of
discharge, are lacking.
Purpose / Aim of Study: To examine the association between
seven evidence based performance
measures; systematic pain
assessment, mobilization before 24
hours postoperatively, basis mobility
assessment at admission and at
discharge, receiving a post discharge
rehabilitation program, anti-
osteoporotic medication, fall prevention
and LOS and readmission within 30
days of discharge among elderly
patients with hip fracture.
Materials and Methods: From the Danish Multidisciplinary Hip
Fracture Registry, we identified 25,354
patients ¡Ý65 years who were admitted
with a hip fracture between March
2010 and November 2013. The
association with LOS and readmission
within 30 days of discharge was
analyzed for the individual
performance measures using
multivariable regression techniques
while controlling for potential
confounders.
Findings / Results: Patients who were mobilized within 24
hours postoperatively had a median
LOS of 8.1 days compared to 9.8 days
for patients mobilized after 24 hours
(adjusted relative time = 0.87 (95% CI:
0.86-0.89). For the remaining six
performance measures, the
differences in LOS were less than 1
day. Furthermore systematic pain
assessment (adjusted odds ratio (OR)
= 0.80 (95% CI: 0.72-0.89)),
mobilization within 24 hours
postoperatively (OR=0.84, 95% CI:
0.78-0.92) and antiosteoporotic
medication (OR=0.79, 95%CI:
0.70-0.88) were all independently
associated with a lower readmission
risk.
Conclusions: Receiving mobilization within 24 hours
postoperatively was associated with
shorter LOS. Receiving systematic
pain assessment, mobilization within
24 hours and anti-osteoporotic
medication was also associated with a
lower risk of readmission among
patients with hip fracture.
24. Bone transport of the femur with a motorized intramedullary lengthening nail.
Søren Kold, Knud Christensen
Orthopaedic, Aalborg University Hospital
Background: Femoral bone defects might be treated with
a bone transport nail.
Purpose / Aim of Study: A retrospective study of the first six
consecutive femoral atrophic non-unions.
Materials and Methods: The atrophic non-union site was resected
and an osteotomy was performed. A
motorized femoral nail capable of combined
bone transport and lengthening was
inserted.
Findings / Results: Treatment failed in a 51-year-old woman as
the sliding screw cut out. Union of the
docking site and distraction callus was
achieved in three women and two men with
a mean age of 49 (23 – 70 years). Mean
defect size was 3 (2 - 5 cm), and mean
limb length discrepancy was 3 (1 - 6 cm).
Mean distraction at the osteotomy site was
6 cm. Minimum distraction at the osteotomy
site was 4 cm (3 cm bone transport and 1
cm bone lengthening) and maximum
distraction at the osteotomy site was 8 cm
(2 cm bone transport and 6 cm bone
lengthening). Mean time to union at the
docking site was 7 months (3 – 10
months). One patient had a persistent limb
length discrepancy of 1 cm. Angular
deformity in the coronal plane went from a
mean preop. value of 7 (0 - 18 degrees) to
a mean postop. value of 1 (0 - 5 degrees).
Angular deformity in the sagittal plane went
from a mean preop. value of 4 (0 - 20
degrees) to a mean postop. value of 3 (0 -
10 degrees). Angular deformity in the axial
plane went from a mean preop. value of 4
(0 - 20 degrees) to a postop. value of 0
degrees in all patients. Patients had full
knee extension at the latest follow-up. Knee
flexion went from a mean preop. value of
100 (45 – 130 degrees) to a mean value of
120 (90 - 140 degrees) at latest follow-up.
Conclusions: Femoral defects in shortened femurs can
be treated by a combined bone transport
and lengthening nail. However, failure
occurred when the sliding screw in the
transport segment was inserted too close
to the resection site.