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Harbrecht A, Hackl M, Ott N, Uschok S, Wegmann K, Müller LP, Leschinger T. Mayo classification of olecranon fractures revisited - Assessment of intra- and interobserver reliability based on CT scans. J Orthop 2024; 52:102-106. [PMID: 38440410 PMCID: PMC10909575 DOI: 10.1016/j.jor.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Purpose Olecranon fractures are classified using the commonly accepted Mayo classification. Its reliability has been analyzed by means of radiographs. A CT scan is often obtained due to joint involvement. Purpose of this study was to evaluate the intra- and interobserver reliability of the Mayo classification based on CT examination. Methods Radiographic and CT images of 20 olecranon fractures were classified by four surgeons at two time points 30 days apart. Intra- and interobserver reliability were assessed using kappa coefficients. Results Mean intraobserver reliability between X-rays was substantial and between CTs almost perfect (0.76 and 0.82, respectively). Mean interobserver reliability was fair for X-rays and moderate for CTs (0.32 and 0.44, respectively). Conclusion Despite the more detailed imaging compared with radiography only moderate interobserver reliability was found for the classification of olecranon fractures based on CT imaging. This might lead to inconsistent fracture classification in both scientific and clinical setting.
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Affiliation(s)
- Andreas Harbrecht
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Michael Hackl
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Nadine Ott
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Stephan Uschok
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
- Orthopädische Chirurgie München, Munich, Germany
| | - Lars P. Müller
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
| | - Tim Leschinger
- University of Cologne, Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, Kerpener Str. 62, 50937, Cologne, Germany
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2
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Rush K, Fisher J, Jain N, Gottlich C, Caroom C. Fixation of Olecranon Fractures Using a Hybrid Intramedullary Screw and Tension Band Construct. Adv Orthop 2024; 2024:6471544. [PMID: 38845777 PMCID: PMC11156510 DOI: 10.1155/2024/6471544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Olecranon fractures are common injuries that require surgical intervention for optimal outcomes. Various fixation methods have been described in the literature, including the use of intramedullary proximal ulna screws in combination with tension band augmentation. Limited research has compared this hybrid technique to other established methods of fixation. This study compared complication and reoperation rates between multiple groups. Methods A retrospective review was conducted on patients with olecranon fractures who underwent internal fixation at a level 1 trauma center between January 1st, 2013, and April 22nd, 2023. Data was collected using CPT codes, and patients were categorized into five groups based on the method of fixation received: no implant, tension band only, locking olecranon plate, intramedullary screw and tension band hybrid, and others. Variables such as patient demographics, Mayo fracture classification, open vs. closed injury, implant type, reoperation rates, and postoperative complications were recorded. Results A total of 217 patients were included in the study. No difference was found with implant choice and reoperation rate (p = 0.461). There was a significant difference found with reoperation and fracture type (p = 0.027) and open fracture (p = 0.002). Conclusion The primary findings of this study indicate no significant difference in implant choice and reoperation rates among the various fixation methods used for olecranon fractures. These findings suggest that the hybrid fixation technique, utilizing intramedullary proximal ulna screws in combination with tension band augmentation, is a viable and comparable treatment option when evaluated against other well-documented methods of fixation. This study also reiterates that severity of initial injury is often the most important factor related to poorer outcomes. Further discussion and analysis of the data will provide a comprehensive understanding of implications and recommendations for olecranon fracture fixation.
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Affiliation(s)
- Kaitlin Rush
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - John Fisher
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Neil Jain
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Caleb Gottlich
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Cyrus Caroom
- Department of Orthopedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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3
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Khanna A, Clark CJ, Yuan BJ, Tangtiphaiboontana J, Barlow JD. Omega Plate Fixation of Comminuted Olecranon Fractures: Technique and Case Series. Tech Hand Up Extrem Surg 2024:00130911-990000000-00096. [PMID: 38556901 DOI: 10.1097/bth.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Fixation of olecranon fractures, especially those with minimal proximal bone and those that present with significant comminution, can be technically challenging. Current open reduction and internal fixation (ORIF) methods, such as tension band wire (TBW) constructs, plate fixation (PF), and intramedullary screws (IMSF), have demonstrated high rates of reoperation and symptomatic implants. We present the omega plate technique, which utilizes a mini-fragment plate passed under the triceps tendon insertion, allowing maximal implant surface area contact with small, proximal olecranon fracture fragments. The mini-fragment plate is not placed on the dorsal subcutaneous border of the ulna, which allows it to capture medial and lateral fragments of cortical comminution and may contribute to less soft tissue irritation.
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Affiliation(s)
- Ankur Khanna
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Clarence J Clark
- Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Rantalaiho IK, Laaksonen I, Kostensalo J, Ekman EM, Ryösä AJ, Äärimaa VO. Mortality and subsequent fractures of patients with olecranon fractures compared to other upper extremity osteoporotic fractures. Shoulder Elbow 2024; 16:186-192. [PMID: 38655414 PMCID: PMC11034465 DOI: 10.1177/17585732221124301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/23/2022] [Accepted: 08/17/2022] [Indexed: 04/26/2024]
Abstract
Background The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures. Methods A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016. Results A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19-3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40-1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22-0.56). Discussion Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.
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Affiliation(s)
- Ida K Rantalaiho
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Inari Laaksonen
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
- University of Turku, Department of Clinical Medicine, Turku, Finland
| | - Joel Kostensalo
- Natural Resources, Natural Resources Institute Finland (Luke), Joensuu, Finland
| | - Elina M Ekman
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Anssi J Ryösä
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Ville O Äärimaa
- Department of Orthopedics and Traumatology, Turku University Hospital, Turku, Finland
- University of Turku, Department of Clinical Medicine, Turku, Finland
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5
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Pohl NB, Brush PL, Russo J, Fras SI, Beredjiklian PK, Fletcher DJ. Triceps Tendon Reattachment Using Mini Plates and Screws After Failure of Olecranon Avulsion Fracture Fixation in Osteoporotic Bone: A Case Report. Hand (N Y) 2024:15589447241238373. [PMID: 38491923 DOI: 10.1177/15589447241238373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
This is a case report of an 85-year-old woman with osteopenia who underwent olecranon avulsion fracture repair with supplemental triceps tendon repair following a fall on an outstretched arm. The initial procedure failed due to osteoporotic bone quality and an atraumatic disruption of the olecranon fracture fixation. The patient subsequently underwent further surgical intervention with an olecranon avulsion fracture excision and a novel triceps tendon repair technique using plate augmentation and fiber tape. Surgeons may consider this novel approach as an initial treatment for elderly patients with osteopenia or osteoporosis undergoing olecranon avulsion fracture fixation, to prevent the failure and consequent revision surgery.
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Affiliation(s)
- Nicholas B Pohl
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Parker L Brush
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - James Russo
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Sebastian I Fras
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Pedro K Beredjiklian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Daniel J Fletcher
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Woolnough T, Caines AM, Pollock JW, Papp SR. Treatment of olecranon fractures in older individuals: a cross-sectional survey of surgeon treatment preferences. JSES Int 2024; 8:227-231. [PMID: 38312299 PMCID: PMC10837697 DOI: 10.1016/j.jseint.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background With an aging population, the incidence of olecranon fractures in older patients is increasing. The standard of care has traditionally included operative management for displaced fractures. Recent literature has called this standard of care into question. Older patients may be at increased risk of operative complications and may have satisfactory functional outcomes with nonoperative management. Given recently evolving evidence, the current treatment preferences of orthopedic surgeons for older patients with displaced olecranon fractures are unknown. Methods We administered a cross-sectional survey of Canadian orthopedic surgeons via e-mail invitation and online survey form to determine treatment preferences for patients aged 65-75 and >75 years with simple displaced and comminuted displaced stable olecranon fractures. Respondents reviewed representative images and were asked to indicate their preferred treatment based on patient age. We also asked respondents to indicate their perceived importance of 11 patient factors on treatment decision-making. Results We received 200 responses (33.8% response rate). For patients aged 65-75 years with simple displaced fractures, surgeons preferred tension-band wiring (n = 110, 56%) to plating (n = 82, 42%, P = .005), while only 3% (n = 5) preferred nonoperative treatment. For patients aged >75 years with simple displaced fractures, surgeons preferred operative (n = 144, 73%) to nonoperative management (n = 51, 26%; P < .01) with either tension-band wiring (n = 77, 39%) or plating (n = 67, 34%). In these patients, early range of motion (n = 35, 18%) was preferred to immobilization (n = 16, 8%; P = .004). For comminuted fractures, plate fixation was preferred for patients aged 65-75 years (n = 189, 95%) and >75 years (n = 131, 68%). In patients aged >75 years, this was followed by early range of motion (n = 35, 18%) and immobilization (n = 24, 13%). Of the 11 factors surveyed, participation in high-intensity activities (mean rank = 9.4), independent living (mean rank = 8.8), and disrupted extensor mechanism (mean rank = 8.3) were ranked most highly for increasing likelihood of surgical treatment. Conclusion In patients aged 65 to 75 years, operative management is favored by most surgeons, with tension-band wiring preferred over plating for simple displaced fractures. In patients aged >75 years, operative management is again preferred by most respondents for simple and comminuted fractures. Despite operative preferences, there is a paucity of quality evidence to guide treatment decision-making, particularly in patients aged >75 years.
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Affiliation(s)
- Taylor Woolnough
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
| | - Andrew M. Caines
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
| | - JW. Pollock
- Division of Orthopaedic Surgery, The Ottawa Hospital – General Campus, Ottawa, ON, Canada
| | - Steven R. Papp
- Division of Orthopaedic Surgery, The Ottawa Hospital – Civic Campus, Ottawa, ON, Canada
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Duckworth AD, Carter TH, Chen MJ, Gardner MJ, Watts AC. Olecranon fractures : current treatment concepts. Bone Joint J 2023; 105-B:112-123. [PMID: 36722062 DOI: 10.1302/0301-620x.105b2.bjj-2022-0703.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, UK
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8
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Qi H, Li Z, Ma T, Du B, Ren C, Xu Y, Huang Q, Zhang K, Lu Y, Li M. A novel internal fixation technique for the treatment of olecranon avulsion fracture. Front Surg 2023; 9:1019767. [PMID: 36726952 PMCID: PMC9886313 DOI: 10.3389/fsurg.2022.1019767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/06/2022] [Indexed: 01/17/2023] Open
Abstract
Objective Tension band wiring and proximal ulnar plate fixation are commonly used fixation methods for olecranon fractures. However, they may not be suitable for repairing proximal olecranon avulsion fractures. In this study, we present a novel fixation technique for the treatment of proximal avulsion fractures, which is a T-shaped plate combined with a wire. Materials and methods Between March 2016 and May 2020, surgery was performed on 16 patients with proximal olecranon avulsion fractures by using a T-shaped plate combined with a wire fixation at our hospital. The parameters followed were fracture healing time, elbow range of motion (ROM), related functional scores (the Mayo score and the DASH score), and complications related to internal fixation. Results The average follow-up period was 17 (14-21) months and fractures had healed in all patients included in the study, with an average fracture union of 9.25 (8-12) weeks. No patient reported fixation failure, serious infection, or revision surgery. The average ROM of the elbow joint was 123° (120-135°). The Mayo score was excellent in 11 patients and good in 5. The average DASH score was 17.75 (12-24). Conclusion Olecranon avulsion fractures were fixed with a T-shaped steel plate combined with a steel wire, which can be used for early functional exercise and for achieving good final functional results. This method can provide stable fixation, especially in elderly patients with osteoporosis.
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Affiliation(s)
| | | | - Teng Ma
- Correspondence: Ming Li Teng Ma
| | | | | | | | | | | | | | - Ming Li
- Correspondence: Ming Li Teng Ma
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9
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Hamoodi Z, Duckworth AD, Watts AC. Olecranon Fractures: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202301000-00009. [PMID: 36638218 DOI: 10.2106/jbjs.rvw.22.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
» Olecranon fractures account for 10% of all elbow fractures and are more likely to result from a low-energy injury. A displaced fracture with a stable ulnohumeral joint (Mayo type 2) is the most common type of injury. » The management of an isolated olecranon fracture is based on patient factors (age, functional demand, and if medically fit to undergo surgery) and fracture characteristics including displacement, fragmentation, and elbow stability. » Nonoperative management can be successfully used in undisplaced fractures (Mayo type 1) and in displaced fractures (Mayo type 2) in frail patients with lower functional demands. » Patients with displaced olecranon fractures with a stable ulnohumeral joint without significant articular surface fragmentation (Mayo type 2A) can be managed with tension band wiring, plate osteosynthesis (PO), intramedullary fixation, or suture repair. » PO is advocated for multifragmentary fractures and fractures that are associated with ulnohumeral instability. It is essential to consider the variable anatomy of the proximal ulna during surgery.
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Affiliation(s)
- Zaid Hamoodi
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
| | - Andrew D Duckworth
- Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
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10
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Möller M, Wolf O, Bergdahl C, Mukka S, Rydberg EM, Hailer NP, Ekelund J, Wennergren D. The Swedish Fracture Register - ten years of experience and 600,000 fractures collected in a National Quality Register. BMC Musculoskelet Disord 2022; 23:141. [PMID: 35148730 PMCID: PMC8832767 DOI: 10.1186/s12891-022-05062-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Before the creation of the Swedish Fracture Register (SFR), there was no national quality register that prospectively collects data regarding all types of fractures regardless of treatment in an emergency setting. Observational data on fractures registered in a sustainable way may provide invaluable tools for quality improvements in health care and research. DESCRIPTION Ten years after its implementation, the Swedish Fracture Register has 100% coverage among orthopaedic and trauma departments in Sweden. The completeness of registrations reached in 2020 69-96% for hip fractures at the different departments, with the majority reporting a completeness above 85%. The Swedish Fracture Register is a fully web-based national quality register created and run by orthopaedic professionals, with financial support from public healthcare providers and the government. All users have full access to both the registration platform and all aggregated statistics in real time. The web-based platform was created for use in health quality registers and it has easily gained acceptance among users. The register has gradually developed by the addition of more fracture types and skeletal parts. Research activity is high and 31 scientific publications have been published since 2016. The strategy from the start was to publish validation data and basic epidemiological data. However, over the past few years, publications on outcomes, such as re-operations and mortality, have been published and four register-based, randomised, controlled trials are ongoing. CONCLUSION It is possible to create a fracture register, to gain professional acceptance and to collect fracture data in a sustainable way on a national level if the platform is easy to use. Such a platform can also be used as a randomisation platform for prospective studies.
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Affiliation(s)
- Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden.
| | - Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Carl Bergdahl
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Science (Orthopaedics), Umeå University, Umeå, Sweden
| | - Emilia Möller Rydberg
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Nils P Hailer
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Jan Ekelund
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - David Wennergren
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
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