Surgical or non-surgical treatment of plantar fasciopathy (SOFT): study protocol for a randomized controlled trial

Background

Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy.

Methods

In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert (n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert (n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment.

Discussion

By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06785-w.

Exploring patient experiences after treatment of humeral shaft fractures: A qualitative study

INTRODUCTION

Humeral shaft fracture treatment can induce serious morbidities, and it is unclear how these morbidities impact patients. To gain in-depth knowledge, we explored how patients experience humeral shaft fractures and the subsequent treatment course.

METHOD

A qualitative study was performed using semi-structured individual interviews. A purposive sampling approach was conducted to recruit patients with traumatic isolated humeral shaft fractures; the patients' ages, genders, primary treatments, and complications varied. Data saturation was met after the data of 12 patients were analyzed using Malterud Systematic Text Condensation.

RESULTS

Eight women and four men with a median age of 48.5 years (range: 22-83 years) were interviewed. The median time from injury to interview was 12.5 months (range: 8-18 months). Ten out of twelve patients were treated non-surgically; of those ten, four patients experienced major complications from the primary treatment. During the analysis, five overarching themes appeared: expectations, physical changes, support and independence, psychological impact, and the specific treatment and recovery.

CONCLUSION

First, patients with humeral shaft fractures expressed frustration with treatment in the emergency department. Second, gross fracture movement and pain were central symptoms that led to the loss of basic capabilities. Third, patient preferences were included in the treatment decision-making process and could change throughout the treatment course. Fourth, patients required massive support to perform basic activities of daily living.

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis

Background

Methods

Results

Conclusion

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

Large hospital variation in the risk of dislocation after primary total hip arthroplasty for primary osteoarthritis: 31,105 patients in 59 hospitals from the Danish Hip Arthroplasty Register

BACKGROUND AND PURPOSE

The risk of dislocation after primary total hip arthroplasty (THA) is affected by several factors, which increases the possibility of substantial differences among hospitals. We compared cumulative incidences of dislocation between regions and hospitals after primary THA surgery in osteoarthritis (OA) patients.

PATIENTS AND METHODS

From the Danish Hip Arthroplasty Register, we included 31,105 THAs performed from 2010 to 2014 with 2 years' follow-up. Dislocations treated by closed reduction were identified in the Danish National Patient Register combined with patient file review. The results are presented as 2-year cumulative incidence on national, regional, and hospital level as proportions with 95% confidence intervals (CI) and as adjusted odds ratios (OR) analyzed by multiple logistic regression.

RESULTS

1,861 dislocations in 1,079 THAs were identified from 59 orthopedic departments. The 2-year cumulative incidence ranged from 2.2% to 4.3% between the 5 regions in Denmark. Hospital variation was 0-12%. For hospitals with a 5-year volume of more than 100 procedures, the incidence was 0.9-7.4%. Using the highest volume hospital as the reference, ORs for dislocation for the remaining hospitals were between 0.3 (CI 0.1-0.6) and 2.7 (1.9-4.0) after adjusting for age, sex, head size, and fixation method. Low-volume hospitals showed a higher dislocation risk than high-volume units with an adjusted OR of 1.2 (1.1-1.4).

INTERPRETATION

We found substantial variation in the incidence of dislocation between hospitals within Denmark, which can be explained by a combination of patient-, component-, and surgery-related factors. There is a need for continuous monitoring of THA dislocation on regional and hospital levels to reduce overall and local dislocation risk for future patients.

Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.

Rehabilitation for life: the effect on physical function of rehabilitation and care in older adults after hip fracture-study protocol for a cluster-randomised stepped-wedge trial

Background

A hip fracture is a serious event for older adults, given that approximately 50% do not regain their habitual level of physical function, and the mortality rate is high, as is the number of readmissions. The gap in healthcare delivery, as separated into two financial and self-governing sectors, might be a contributing cause of inferior rehabilitation and care for these patients. Therefore, we aim to assess the effect of continuous and progressive rehabilitation and care across sectors for older adults after hip fracture.

Methods/design

The project is designed as a stepped-wedge cluster randomised controlled trial. The study population of patients are older adults 65 years of age and above discharged after a hip fracture and healthcare professionals in primary and secondary care (municipalities and hospitals). Healthcare professionals from different sectors (hospital and municipalities) will be engaged in the empowerment-orientated praxis, through a workshop for healthcare professionals with knowledge sharing to the older adults using a digital health application (app). The rehabilitation intervention consists of 12 weeks of progressive resistance exercises initiated 1–2 days after discharge. To improve communication across sectors, a videoconference involving the patient and physiotherapists from both sectors will be conducted. On day, 3 after discharge, an outreach nurse performs a thorough assessment including measurement of vital signs. A hotline to the hospital for medical advice is a part of the intervention. The intervention is delivered as an add-on to the usual rehabilitation and care, and it involves one regional hospital and the municipalities within the catchment area of the hospital. The primary outcome is a Timed Up and Go Test 8 weeks post-surgery.

Discussion

Using a stepped-wedge design, the intervention will be assessed as well as implemented in hospital and municipalities, hopefully for the benefit of older adults after hip fracture. Furthermore, the collaboration between the sectors is expected to improve.

Trial registration

The study is approved by the Regional Scientific Ethics Committees of Southern Denmark (S-20200070) and the Danish Data Protection Agency (20-21854). Registered 9 of June 2020 at ClinicalTrials.gov, NCT04424186.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06321-w.

Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population.

INTRODUCTION

Knowledge on younger patients with hip fractures is limited. Common preconceptions are that they suffer fractures due to high-energy trauma, alcohol or substance use disorder but not associated to osteoporosis. We aimed to descriptively analyze the characteristics of young and middle-aged patients with hip fractures and examine bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) at the time of the fracture.

METHODS

A prospective multicenter cohort study on adult patients with hip fractures below age 60 collected detailed information on patient characteristics regarding demographics, trauma mechanism, previous fractures, comorbidity and medication, and lifestyle factors. DXA results were compared to population-based reference data.

RESULTS

The cohort contains 91 women and 127 men, median age 53 (IQR 47-57). Most fractures, 83%, occurred in patients aged 45-59. Two-thirds of all fractures resulted from low-energy trauma. Half of the patients had prior fractures after age 20. Thirty-four percent were healthy, 31% had one previous disease, and 35% had multiple comorbidities. Use of medication associated with increased fracture risk was 32%. Smoking was prevalent in 42%, harmful alcohol use reported by 29%, and signs of drug-related problems by 8%. Osteoporosis according to WHO criteria was found in 31%, osteopenia in 57%, and normal BMD in 12%.

CONCLUSION

In patients with hip fractures below age 60, risk factors for osteoporosis and fractures were numerous. Moreover, the prevalence of osteoporosis was markedly higher than in the general population. We suggest that young and middle-aged patients with hip fractures undergo a thorough health investigation including DXA, regardless of trauma mechanism.

Secondary surgeries 20 years after surgical and non-surgical treatment of ACL rupture: A population-based cohort study

BACKGROUND

Studies with less than 10 years of follow-up have demonstrated no difference between surgical and non-surgical treatment after an anterior cruciate ligament (ACL) rupture; however, long-term effects remain unclear. The aim of this study was to compare the risk of long-term secondary surgical procedures after primary surgical and non-surgical treatment for ACL ruptures.

METHODS

Patients aged 18-35, registered in the Danish National Patient Registry with an ACL rupture between January 1, 1996 and December 31, 2000 with a minimum of 20 years follow-up were included. The surgically treated group was defined as receiving an ACL reconstruction within 1 year after diagnosis. Major secondary surgical procedures were defined as subsequent ACL surgeries (reconstruction/revision), arthroplasty, deep infection, arthrodesis, or amputation. Minor secondary surgical procedures were defined as meniscal surgery, synovectomy, and manipulation under anesthesia (MUA). Multivariate regression analysis was performed to assess relative risk (RR), adjusted for age and sex. The results are reported with 95% confidence intervals.

RESULTS

7,539 patients had an ACL rupture; 1,970 patients were surgically treated. In the surgically treated group, 5.9% of patients underwent major secondary surgeries; this was 6.1% in the non-surgically treated group, yielding an adjusted RR of 1.05 (0.85;1.30). There were 43.9% minor secondary surgeries in the surgically treated group and 49.1% in the non-surgically treated group, yielding an adjusted RR of 1.29 (1.20;1.39).

CONCLUSIONS

No significant differences in the rate of major secondary surgical procedures between the groups, the non-surgical group was associated with a higher risk of minor secondary surgeries.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis

OBJECTIVE

to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM).

MATERIALS AND METHODS

Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate.

RESULTS

Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures.

CONCLUSION

No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

Arterial Blood Gas Analysis: as safe as we think? A multicentre historical cohort study

Purpose

Methods

Results

Conclusion

Arterial punctures for arterial blood gas analysis are safe procedures with a major complication rate within 7 days of 0.14% (95% CI 0.13–0.15%). Patients on antithrombotic medication have an increased risk of developing major complications.https://bit.ly/3FaPOwk

Risk of mortality and reoperation in hip fracture patients undergoing cemented versus uncemented hemiarthroplasty : a population-based study from Danish National Registries

AIMS

The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years.

METHODS

This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs).

RESULTS

A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83).

CONCLUSION

In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127-133.

Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?: A Multicenter Cohort Study

BACKGROUND

The purpose of the present multicenter cohort study was to compare the rates of reoperation in elderly patients with pertrochanteric and subtrochanteric fractures that had been treated with a short or long intramedullary nail.

METHODS

Eleven orthopaedic departments across Denmark delivered data that had been obtained from the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and a review of health-care records. With use of surgical procedure codes for pertrochanteric and subtrochanteric fractures that had been treated with an intramedullary nail, the DMRHF was searched to identify patients who had been ≥65 years of age between 2008 and 2013. The health-care records for patients who had had major reoperations, defined as any reoperation with the exclusion of simple hardware removal, were retrieved from the DMHFR, were reviewed for the type of intramedullary nail and missed reoperations, including peri-implant fractures, within 2 years of follow-up. Crude logistic regression analysis with adjustment for age, sex, and comorbidity was performed, yielding odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Of 2,245 pertrochanteric fractures, 1,867 were treated with a short intramedullary nail and 378 were treated with a long intramedullary nail. The rate of major reoperations was 4.0% in the short intramedullary nail group and 6.3% in the long intramedullary nail group. This yielded a crude OR of 1.61 (1.01 to 2.60) and an adjusted OR of 1.67 (1.04 to 2.70). Of 909 subtrochanteric fractures, 308 were treated with a short intramedullary nail and 601 were treated with a long intramedullary nail. The rate of major reoperations was 8.4% in the short intramedullary nail group and 4.0% in the long intramedullary nail group, yielding a crude OR of 0.45 (0.25 to 0.80) and an adjusted OR of 0.45 (0.25 to 0.81).

CONCLUSIONS

This is the first study confirming the theory that, for subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail. In contrast, a short intramedullary nail has a lower rate of major reoperations compared with a long intramedullary nail for pertrochanteric fractures but with a lower absolute risk reduction compared with the results for subtrochanteric intramedullary nailing. There is a need for validation of these results in other large studies, especially for pertrochanteric fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid: When is It Indicated in Orthopaedic Surgery?

Tranexamic acid (TXA) has been studied extensively during the last 5-8 years. It inhibits clot dissolution during surgery and can therefore reduce blood loss. However, there has been concern that this could result in more frequent complications, specifically in terms of thromboembolic events. The indications for TXA are widespread, and this review covers the literature on orthopaedic indications such as joint replacement, fracture surgery, and arthroscopic procedures. In general, TXA is safe and can be used in a wide variety of orthopaedic procedures, lowering blood loss without increasing the risk of complications.

Standardized, Coordinated Care in Nursing Homes Lowers Rehospitalization After Hip Fracture

OBJECTIVES

To assess the effect of enhanced standardized interdisciplinary cooperation between the orthogeriatric ward, municipality, and nursing home facility (NHF) on readmission rates in patients with hip fracture.

DESIGN

Quasi-experimental design with a nonequivalent control group.

SETTING AND PARTICIPANTS

From January 2018 to July 2020, patients with hip fracture who were admitted to the department of orthopedic surgery and traumatology at Lillebaelt Hospital, and later discharged to NHF were included.

INTERVENTION

The intervention consisted of a safety program to the NHF for the first 14 days postdischarge and included assessment of vital signs, weight, pain, signs of constipation, hours of mobilization, and daily intake of fluids and high-protein beverages. Acute team nurses undertook visits (planned and unplanned) and could take blood samples and administer intravenous fluids or antibiotics at the NHF. Control participants received usual care.

METHODS

The intervention was performed in 2 municipalities with an acute team; the remaining 3 municipalities comprised the control group. The primary outcome was 30-day readmission, and secondary outcomes were mortality, mobility, and quality of life.

RESULTS

There were 100 patients in the intervention group and 152 in the control group. The median age was 86 years, 68% were female, and more than 60% had a low mental score; there were no statistical differences between groups in baseline variables. The 30-day readmission rate was 14% in the intervention group and 30% in the control group (P = .004). The 30-day mortality rate was 6% in the intervention group and 13% in the control group (P = .07). There was no statistically significant difference in mobility between the 2 groups but there was a higher health-related quality of life score in the intervention group (P = .045).

CONCLUSIONS AND IMPLICATIONS

Enhanced standardized interdisciplinary cooperation between hospital, NHF teams, and visiting acute team nurses can lower readmissions and potentially mortality.

The use of negative pressure wound therapy for fracture-related infections following internal osteosynthesis of the extremity: A systematic review

This study aimed to systematically review the current literature on studies using negative pressure wound therapy (NPWT) or dressings following fracture-related infection (FRI) in internal osteosynthesis of the extremity. Articles were analyzed on fracture and wound healing and included when comparing or describing the use of either NPWT or dressings in FRI. We conducted a systematic literature search in four electronic databases: Embase, Medline, the Cochrane Library, and Scopus. The studies were screened by two authors using Covidence.org and evaluated for risk of bias. A total of 8576 records were identified. No articles compared NPWT to dressings. Seven case reports and three case series included a total of 115 patients treated for FRI. Fracture healing was achieved in 21 out of 67 patients treated with NPWT (4 amputations and 46 not described) and all 48 patients in the dressing group (4 patients needed additional sequestrectomy procedures). Five studies did not describe fracture healing. In 57 out of 67 patients treated with NPWT, the wounds were described as healed, closed, or requiring soft tissue reconstruction (4 amputations and six lacking description). The dressing group had complete wound coverage in 18 patients and partial coverage in 30 patients. Studies were generally at high risk of bias because of insufficient descriptions of both patient demographics and outcomes. No studies compared NPWT to dressings, and the existing literature is at high risk of bias. The included studies were of low-level evidence. NPWT can be neither recommended nor advised against to cover infected osteosynthesis.

Less improvement following meniscal repair compared with arthroscopic partial meniscectomy: a prospective cohort study of patient-reported outcomes in 150 young adults at 1- and 5-years' follow-up

Background and purpose - Meniscal repair may reduce long-term risk of knee osteoarthritis compared with arthroscopic partial meniscectomy (APM), whereas patient-reported outcomes may be poorer at short term than for APM. We compared patient-reported outcomes in young adults undergoing meniscal repair or APM up to ∼5 years after surgery.Patients and methods - We included 150 patients aged 18-40 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing meniscal repair or APM. Between-group differences in change in a composite of 4 of 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, sport and recreation, and quality of life-KOOS₄) from baseline, 12, and 52 weeks, and a median of 5 years (range 4-6 years) were analyzed using adjusted mixed linear models, with 52 weeks being the primary endpoint.Results - 32 patients had meniscal repair (mean age 26 [SD 6]), and 118 patients underwent APM (mean age 32 [SD 7]). The repair and APM groups improved in KOOS₄ from before to 52 weeks after surgery (least square means 7 and 19, respectively; adjusted mean difference -12, [95% CI -19 to -4] in favor of APM). Both groups improved further from 52 weeks to 5 years after surgery with the difference in KOOS₄ scores between the groups remaining similar.Interpretation - Patients having meniscal repair experienced less improvements in patient-reported outcomes from baseline to 52 weeks and 5 years post-surgery. The findings highlight the need for randomized trials comparing these interventions in terms of patient-reported outcomes and knee OA development.

The ability of comorbidity indices to predict mortality in an orthopedic setting: a systematic review

BACKGROUND

Several comorbidity indices have been created to estimate and adjust for the burden of comorbidity. The objective of this systematic review was to evaluate and compare the ability of different comorbidity indices to predict mortality in an orthopedic setting.

METHODS

A systematic search was conducted in Embase, MEDLINE, and Cochrane Library. The search were constructed around two primary focal points: a comorbidity index and orthopedics. The last search were performed on 13 June 2019. Eligibility criteria were participants with orthopedic conditions or who underwent an orthopedic procedure, a comparison between comorbidity indices that used administrative data, and reported mortality as outcome. Two independent reviewers screened the studies using Covidence. The area under the curve (AUC) was chosen as the primary effect estimate.

RESULTS

Of the 5338 studies identified, 16 met the eligibility criteria. The predictive ability of the different comorbidity indices ranged from poor (AUC < 0.70) to excellent (AUC ≥ 0.90). The majority of the included studies compared the Elixhauser Comorbidity Index (ECI) and the Charlson Comorbidity Index (CCI). In-hospital mortality was reported in eight studies reporting AUC values ranging from 0.70 to 0.92 for ECI and 0.68 to 0.89 for CCI. AUC values were generally lower for all other time points ranging from 0.67 to 0.78. For 1-year mortality the overall effect size ranging from 0.67 to 0.77 for ECI and 0.69 to 0.77 for CCI.

CONCLUSION

The results of this review indicate that the ECI and CCI can equally be used to adjust for comorbidities when analyzing mortality in an orthopedic setting.

TRIAL REGISTRATION

The protocol for this systematic review was registered on PROSPERO, the International Prospective Register of Systematic Reviews on 13 June 2019 and can be accessed through record ID 133,871.

Danish translation and validation of the Self-reported foot and ankle score (SEFAS) in patients with ankle related fractures

BACKGROUND

The Self-reported Foot and Ankle Score (SEFAS) is a patient-reported outcome measure used to evaluate foot and ankle disorders. The purpose of this study was to translate, cross-culturally adapt and validate the Danish language version of the SEFAS in patients with ankle-related fractures.

METHODS

Forward-backward translation, cross-cultural adaption and validation were performed. In total, 125 patients completed the SEFAS-DK and the Danish version of American Orthopaedic Foot and Ankle Score (AOFAS-DK) at three time points after the date of fracture. The evaluation was performed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

The intra-class correlation coefficient (ICC) level of the SEFAS-DK total score was 0.93 (95% confidence interval [CI]: 0.88-0.96). Cronbach's alpha (CA) for the SEFAS-DK was 0.93, while the floor and ceiling effect at week 6 post-injury was 22.4%. Construct validity was correlated with the AOFAS, and >75% of the pre-defined hypotheses could be confirmed. Responsiveness was analysed using longitudinal data. The minimal clinical important change (MCIC) showed that the SEFAS-DK detects changes in physical function over time.

CONCLUSION

The Danish version of the SEFAS showed overall good reliability, validity and responsiveness. SEFAS-DK can be used to evaluate physical function in patients with ankle-related fractures.

LEVEL OF EVIDENCE

level II, prospective cohort study.

Danish Language Version of the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) in Patients with Ankle-Related Fractures

The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) is, to date, the most widely used scale for evaluating foot and ankle disorders. We translated it into Danish and evaluated the reliability, validity and responsiveness of the Danish version of the AOFAS-AHS (AOFAS-DK) in patients aged >18 years with isolated ankle-related fractures. Forward-backward translation, cross-cultural adaption, and validation study were performed. In total, 125 patients completed the AOFAS-DK and the Self-reported Foot and Ankle Score (SEFAS) at 3 time points after the date of fracture. The evaluation was performed according to the Consensus-based Standards for the selection of health Measurement Instruments guidelines. The intra-class correlation coefficient level of the AOFAS-DK total score was 0.87 (95% confidence interval: 0.80-0.91). Cronbach's alpha (CA) for the AOFAS-DK function subscale was 0.62, whereas the floor and ceiling effect of the function subscale was 32% (T1) and 19% (T2), respectively. Construct validity was correlated with the SEFAS, and >75% of the predefined hypotheses could be confirmed. Responsiveness was analyzed using longitudinal data, and showed that the AOFAS-DK can detect changes in scores. The Danish version of the self-administered section of the AOFAS-AHS showed overall good reliability, validity, and responsiveness. The low CA values and the presence of the floor effect might be due to the low number of items and response options available in the scale. The AOFAS-DK can be used to evaluate physical function in patients with ankle-related fractures.

Impact of compression stockings on wound healing and complications in ankle fractures: A retrospective cohort study

INTRODUCTION

Ankle fractures treated with open reduction and internal fixation (ORIF) have a high incidence of wound complications. By reducing oedema, wound complications can, in theory, be minimized. This study investigates the impact of compression stocking (CS) on such complications after treatment with ORIF.

METHODS

Compression stockings were introduced as a standard postoperative treatment for all ankle fracture patients treated operatively with ORIF on February 1, 2013. Data were retrieved from medical records two years prior to and following the introduction date. The primary outcome was wound healing status after six weeks and secondary outcomes were wound-healing and major complications up to one year after surgery.

RESULTS

In total, 187 patients were studied, 74 in the CS group and 113 in the control (non-CS) group. Six weeks after the operation, wound-healing problems occurred in 23% and 13% of the patients in the CS group and the non-CS group (p < 0.0001) respectively. In total, 34% and 19% of the patients in the CS group and non-CS group experienced wound-healing complications one year after the operation (p < 0.02) respectively. Furthermore, major complications within one year occurred in 3% and 4% of patients respectively (p < 0.77).

CONCLUSION

An increase in wound-healing complications after six weeks and one year when using CS was found. However, owing to baseline differences in the two groups, it is only possible to caution against the use of CS.

Cemented hemiarthroplasty for femoral neck fracture patients: collarless, polished tapered stem (CPT) versus anatomic matte stem (Lubinus SP2)

BACKGROUND

Cemented hemiarthroplasty is a well-documented treatment for patients with femoral neck fractures (FNFs). However, there are not many cohort studies comparing different types of hemiarthroplasty (HA).

OBJECTIVE

To compare CPT and Lubinus SP2 HA for FNF patients concerning complications and radiological measurements.

METHODS

From January 1, 2013, CPT was introduced instead of Lubinus SP2 as the new cemented HA due to a regional procurement. Data were retrieved 3 years prior and after the introduction. All patient health records were retrospectively reviewed for types of implant, American Society of Anesthesiologists (ASA) score and duration of admission. All X-ray images were analyzed for radiological measurements concerning offset, stem angulation and cement filling. Mortality and major complications within 1 year were retrieved from patient health records as well as the Danish National Patient Registry. Major complications were defined as dislocations, periprosthetic fractures and revisions.

RESULTS

584 cemented HA were included, 300 CPT and 284 with Lubinus SP2. The mean age (SD) was 82 (8.2) years, and there was no baseline difference between the groups concerning age, sex, ASA score and mortality. There were 8.7% major complications for CPT and 9.2% for Lubinus SP2 (p = 0.836). There were, however, seven periprosthetic fractures in the CPT group and one in the Lubinus SP2 group (p = 0.04). In contrast, there were 20 dislocations in the Lubinus SP2 group and 10 in the CPT group (p = 0.042). There was no statistical difference between the stem angulation and periprosthetic fractures (p = 0.824) or major complications (p = 0.602). The Lubinus SP2 had a mean plus 2.7 mm offset postoperatively (p = 0.001), while the CPT had plus 10.6 mm (p < 0.000). The mean (SD) angle of the stems was 1.39 (1.75) degrees for Lubinus SP2 and 2.46 (1.99) for CPT. There was no difference in cementation (p = 0.308).

CONCLUSION

There was no overall statistical difference between the CPT and Lubinus SP2 stem regarding major complications. However, the CPT had a higher prevalence of periprosthetic fractures, while the Lubinus SP2 had a higher dislocation prevalence. The CPT stem had overcorrection of offset and a higher degree of varus positioning.

Development of a diagnostic algorithm identifying cases of dislocation after primary total hip arthroplasty-based on 31,762 patients from the Danish Hip Arthroplasty Register

Background and purpose - Dislocation of total hip arthroplasties (THA) is often treated with closed reduction and traditionally not registered in orthopedic registers. This study aimed to create an algorithm designed to identify cases of dislocations of THAs with high sensitivity, specificity, and positive predictive value (PPV) based on codes from the Danish National Patient Register (DNPR).Patients and methods - All patients (n = 31,762) with primary osteoarthritis undergoing THA from January 1, 2010 to December 31, 2014 were included from the Danish Hip Arthroplasty Register (DHR). We extracted available data for every hospital contact in the DNPR during a 2-year follow-up period, then conducted a comprehensive nationwide review of 5,096 patient files to register all dislocations and applied codes.Results - We identified 1,890 hip dislocations among 1,094 of the included 31,762 THAs. More than 70 different diagnoses and 55 procedural codes were coupled to the hospital contacts with dislocation. A combination of the correct codes produced a sensitivity of 63% and a PPV of 98%. Adding alternative and often applied codes increased the sensitivity to 91%, while the PPV was maintained at 93%. Additional steps increased sensitivity to 95% but at the expense of an unacceptable decrease in the PPV to 82%. Specificity was, in all steps, greater than 99%.Interpretation - The developed algorithm achieved high and acceptable values for sensitivity, specificity, and predictive values. We found that surgeons in most cases coded correctly. However, the codes were not always transferred to the discharge summary. In perspective, this kind of algorithm may be used in Danish quality registers.