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Objectives: Electrocardiogram (ECG) and measurement of plasma brain natriuretic peptides (BNP) are established markers of right ventricular dysfunction (RVD) in the setting of acute pulmonary embolism (PE) but their value at long-term follow-up is largely unknown. The purpose of this prospective study was to determine the prevalence of ECG abnormalities, describe levels of N-terminal proBNP (NT-proBNP), and establish their association with dyspnea at long-term follow-up after PE., Design: All Swedish patients diagnosed with acute PE in 2005 ( n  = 5793) were identified through the Swedish National Patient Registry. Surviving patients in 2007 ( n  = 3510) were invited to participate. Of these, 2105 subjects responded to a questionnaire about dyspnea and comorbidities. Subjects with dyspnea or risk factors for development of chronic thromboembolic pulmonary hypertension were included in the study in a secondary step, which involved collection of blood samples and ECG registration., Results: Altogether 49.3% had a completely normal ECG. The remaining participants had a variety of abnormalities, 7.2% had atrial fibrillation/flutter (AF). ECG with any sign of RVD was found in 7.2% of subjects. Right bundle branch block was the most common RVD sign with a prevalence of 6.4%. An abnormal ECG was associated with dyspnea. AF was associated with dyspnea, whereas ECG signs of RVD were not. 61.2% of subjects had NT-proBNP levels above clinical cut-off (>125 ng/L). The degree of dyspnea did not associate independently with NT-proBNP levels., Conclusions: We conclude that the value of ECG and NT-proBNP in long term follow-up after PE lies mostly in differential diagnostics.

Dyspnea is common after a pulmonary embolism. Often, but not always, the dyspnea can be explained by pre-existing comorbidities, and only rarely by chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is probably the extreme manifestation of a far more common condition, called the post-pulmonary embolism syndrome. The purpose of this retrospective study was to investigate the prevalence and predictors of dyspnea among Swedish patients that survived a pulmonary embolism, compared to the general population. All Swedish patients diagnosed with an acute pulmonary embolism in 2005 (n = 5793) were identified via the Swedish National Patient Registry. Patients that lived until 2007 (n = 3510) were invited to participate. Of these, 2105 patients responded to a questionnaire about dyspnea and comorbidities. Data from the general population (n = 1905) were acquired from the multinational MONItoring of trends and determinants in CArdiovascular disease health survey, conducted in 2004. Patients with pulmonary embolism had substantially higher prevalences of both exertional dyspnea (53.0% vs. 17.3%, odds ratio (OR): 5.40, 95% confidence intervals (CI): 4.61-6.32) and wake-up dyspnea (12.0% vs. 1.7%, OR: 7.7, 95% CI: 5.28-11.23) compared to control subjects. These differences remained after adjustments and were most pronounced among younger patients. The increased risk for exertional dyspnea and wake-up dyspnea remained after propensity score matching (OR (95% CI): 4.11 (3.14-5.38) and 3.44 (1.95-6.06), respectively). This population-based, nation-wide study demonstrated that self-reported dyspnea was common among patients with previous pulmonary embolism. This finding suggested that a post-pulmonary embolism syndrome might be present, which merits further investigation., (© The Author(s) 2021.)

Summary: Polymethylmethacrylate, as a widely used material for vertebroplasty, has several drawbacks such as heat development and high allergenic potential. In order to avoid these drawbacks ceramic cement materials have been developed. The purpose of this study was to evaluate a new biointegrative material for vertebroplasty in osteoporotic vertebral fractures regarding pain relief, safety aspects and technical feasibility. The injectable bone substitute Cerament(TM) SpineSupport has been developed for vertebroplasty of osteoporotic vertebral fractures. The aim of the product is to provide mechanical stability by cured calcium sulfate dehydrate during a period of several weeks and to act as an osteoconductive support by hydroxyl apatite particles. Inclusion criteria were a stable single vertebral fracture at levels Th5 to L5, verified by CT and MRI, and not older than four weeks, in osteoporotic patients aged 60 years or older. Bipedicular vertebroplasty technique was used. Follow up included CT directly after treatment and after two month and pain assessment (VAS) pre and post procedure after two weeks and one month. Seven patients (age range 62 - 96 years, mean 73.9, five women, two men) were treated at levels T 8 (n=1), T 12 (n=4) and L1 (n=2). The average injected volume was 1.9 ml (range 0.2-4 ml). No material or procedure-related complications were observed. An average height loss of the treated vertebral bodies of 3.6 mm (range 1.5-5.4) was seen two months after treatment as compared to pre-treatment CT. Pain assessment by VAS resulted in an improvement from mean 69 prior treatment to 37 the day post treatment, 42 after two weeks and 30 after one month. Initial results indicate that Cerament(TM) SpineSupport is safe and effective in the treatment of acute osteoporotic vertebral body fractures. Further studies with long-term follow-up are needed to confirm these results and to prove the concept of osteoconduction with hydroxyl apatite particles.

Background: The Swedish Lumbar Spine Register has been collecting patient-based data since 2000, and more than 80% of all spinal units in Sweden are now including their patients. In a few years, it will produce useful clinical information just as arthroplasty registers have, but to permit proper interpretation of data in the future, the reliability of the protocol must be tested., Methods: Between January 2000 and March 2003, a sample of 122 patients was asked to fill in the questionnaire twice: 63 preoperatively and 59 postoperatively. Test-retest reliability was calculated with intra-class correlation coefficient (ICC) or weighted kappa when appropriate., Results: Test-retest interval varied (range 0-235 days); in the "worst case scenario", the lowest ICC for SF-36 was 0.62 for the postoperative RE. Other values were above 0.70; for non-SF variables, ICC was in the range 0.79-0.89. Kappa values for the ordinal outcomes were high (0.74-0.91)., Interpretation: When separate reliability analysis was performed according to the time interval, a 0-2 days interval produced a significant memory effect; after 3 weeks, the reliability seemed to drop in the preoperative group, whereas results were reproducible up to 9 weeks postoperatively. The protocol studied can reliably detect postoperative improvements between large groups of patients such as in a register.

We have previously studied the radiographic outcome of femoral neck fracture osteosynthesis with either two hook-pins or a four-flanged nail performed by a small group of surgeons with special interest in the methods. In 138 femoral neck fractures a backwards stepwise logistic regression analysis was used to study the significance of preoperative fracture-related factors, intraoperative factors and the osteosynthesis. The development of non-union/redisplacement and segmental collapse of the femoral head was influenced by fracture displacement (P 0.001) and method of osteosynthesis (P 0.007). The postoperative scintimetric ratio was influenced by the method of osteosynthesis (P 0.0003), fracture displacement (P 0.004) and by the presence of a posterior fragment (P 0.03). Reduction of the fracture and positioning of the osteosynthesis were to a large extent within the accepted limits. This may explain why the previously well documented negative effects of malpositioning of the osteosynthesis and inferior reduction were not demonstrated to influence the rate of healing-complications. We conclude that neither patient age, sex nor preoperative fracture variables, with the exception of the extent of fracture displacement, can be used to predict radiographic healing-complications in femoral neck fractures.

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

A 2-year follow-up regarding healing complications, such as redisplacement, nonunion, and segmental collapse of the femoral head, was performed in 306 patients operated on for femoral neck fracture and examined with 99mTechnetium-MDP scintimetry within 2 weeks postoperatively. Scintimetric evaluation was performed by selecting regions of interest over the femoral head on the fracture side and the intact side and by comparing the uptake. A femoral head ratio fractured/intact side thus was obtained. Of 199 patients with an intact femoral head uptake (ratio greater than or equal to 1.0), 181 showed no signs of healing complications at 2 years, whereas 18 had developed healing complications. Of 107 cases with a deficient femoral-head uptake (ratio less than 1.0), 96 had developed healing complications within 2 years from the operation, while 11 cases had no signs of radiographic complications. We conclude that 99mTc-MDP scintimetry performed within 2 weeks from femoral neck fracture can predict the outcome of the healing course with a prognostic accuracy of 91 per cent.

Two elderly patients had pain after hip trauma with no radiographic evidence of fracture. Computed tomography demonstrated capsular haematoma. Scintimetry revealed femoral head ischaemia. Intracapsular hip joint pressure in extension was 240 and 176 mm Hg, respectively, in neutral position and 280 and 360 mm Hg in internal rotation. The hip joints were aspirated for 8 ml and 5 ml of blood, respectively, leading to pain relief and regained radiotracer uptake in the femoral head. It is concluded that traumatic hip joint tamponade may cause femoral head ischaemia which may be reversed by aspiration.

In a retrospective population-based study, 510 consecutive cervical hip fractures treated by internal fixation with a spring-loaded four-flanged nail, early weight bearing, and social rehabilitation were examined at 5 years after primary nailing. Six (1.6 percent) deep infections occurred. After a new trauma, seven fractures through the nail entrance were seen. Mortality at 2 years was 32 percent and at 5 years 53 percent. With a program for active rehabilitation, 80 percent of the survivors coming from independent living returned to this and remained there. The frequency of reoperations in patients below age 70 years was twice as high as in those over 70. Secondary arthroplasty was performed in 6 percent of the 129 undisplaced fractures and in 25 percent of the 381 displaced fractures. Totally, 67 percent of the fractures had no secondary procedure, not even nail extraction.

32 patients, suffering from Parkinson's disease, had internal fixation of femoral neck fractures. In 24 displaced fractures, 6 nonunions and 3 segmental collapses were seen; and in 8 undisplaced fractures, 1 case of segmental collapse was diagnosed. Healing complications were thus seen in one third. Total hip replacement for healing complication was performed in 3 of 32 patients. 9 patients died within 2 years. No difference in the rate of healing or mortality was detected compared with hip fracture patients without Parkinson's disease. Our study does not support primary arthroplasty for femoral neck fracture in patients with Parkinson's disease.

In eight undisplaced intracapsular fractures of the femoral neck, an intracapsular hematoma was diagnosed by computed tomography. 99mTc-MDP scintimetry revealed markedly reduced or absent blood supply to the head of femur. The intracapsular pressure was 23 (2.7-43) kPa with the hip in neutral position. Following aspiration of 12 (0.5-36) ml of blood, pressure was reduced to zero, and postaspiration scintimetry revealed restitution of blood supply to the femoral head. Hip joint tamponade in these patients has caused femoral head ischemia, reversible by aspiration.

For 14 consecutive months, all 152 femoral neck fracture patients greater than or equal to 50 years of age admitted to the Lund University Hospital were operated on with two hook-pins if born on an uneven date and a four-flanged nail if born on an even date. A clinical 2-year follow-up revealed a 35 per cent mortality. Among survivors, radiographic healing complications were seen in undisplaced fractures in 1/13 pinned and 5/14 nailed (p greater than 0.05) and in displaced fractures in 12/36 pinned and 23/32 nailed (p less than 0.01). This outcome correlated well with the early postoperative scintimetry. Reoperation within 2 years had been performed for seven pinned and 19 nailed fractures. In hook-pinning, thus, less than one patient out of 12 needed a reoperation with THR within 2 years. This figure is interpreted as strongly favouring hook-pinning before arthroplasty as the primary procedure in femoral neck fracture.

An 81-year-old woman had severe hip pain after a fall. Radiography was normal, but computed tomography and sonography showed a minor, displaced acetabular fracture and hemarthrosis. Aspiration of 15 ml of blood reduced the intracapsular pressure in the neutral position from 30 kPa to atmospheric pressure with relief of pain and increased joint motion. This case confirms that acetabular fracture may escape radiographic diagnosis and cause hip joint tamponade. Aspiration should be considered as a palliative and possibly therapeutic measure.

In 34 femoral neck fractures, CT was performed within 1-32 days after internal fixation. All the cases except one showed an increased distance between the femoral neck and the anterior aspect of the joint capsule as compared with the intact side, indicating varying degrees of hip joint effusion and/or synovitis. Hip joint aspiration in 11 patients revealed increased intracapsular pressure varying between 10 and 112 mmHg and volumes of aspirated joint effusion up to 23 ml. Pain relief and increased joint motion after drainage of the intracapsular effusion was observed in 3 patients whose postoperative mobilization was facilitated.

Totally, 191 consecutive patients with femoral neck fractures during 1984 and 1985 had internal fixation with hook-pins and were prospectively investigated. Within 2 years, 62 patients had died and 47 had developed healing complications, 30 of whom had been treated with total hip replacement. Thus, 82 healed without complication. Forty-one of 47 patients without other handicaps affecting their walking ability considered their gait as good as it was preoperatively; 45 used no walking aids or a cane. Nine of 35 patients with a nonfracture-related disease affecting their walking ability managed to walk with or without a cane; 13 considered their walking ability unaltered compared with their prefracture state. Three of 82 patients complained of pain on walking and 2 of pain at rest. All but 1 could flex their hip 90 degrees or more. We believe that the function after internal fixation of cervical hip fracture with uncomplicated healing is superior to that achieved by primary hip replacement; primary replacement is recommended only in rheumatoid patients with displaced fractures.