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Background and purpose: A femoral neck fracture (FNF) may have long-term effects on the patient's func-tion, also in patients younger than 70 years. These long-term effects are not well described, since most studies have short follow-ups. The aim of this study was to investigate clinical outcome by performance -based functional tests, hand grip strength, and hip function in different subgroups. The secondary aim was to study surgical complications, bone mineral density (BMD) and occurrence of sarcopenia 10 years after a FNF. Patients and methods: A prospective multicenter study with a 10-year follow-up of patients aged 20- 69 years with a FNF treated with internal fixation (IF). Five-times sit-to-stand test (5TSST), 4-m walking speed test, hand grip strength (HGS) and Harris Hip Score (HHS) were performed.A radiographic examination of the hip was performed and re-operations were registered. Bone min-eral density (BMD) at the hip, spine and total body composition were assessed with dual energy x-ray absorptiometry (DXA). Present sarcopenia was determined by the combination of reduced functional per-formance and low fat-free mass index (FFMI).Results: A total of 58 patients were included. 5TSTS was normal in 45% of the patients and old age was associated with poorer performance ( p < 0.001). 76% of the study population had a normal speed gait and likewise, old age ( p = 0.005) and walking aids ( p = 0.001) were associated with poor performance. HGS was normal in 82% of the men and 64% of the women. HHS showed that 85% had a good/excellent function. A major re-operation was performed in 34% of the patients with displaced FNF and in 20% of patients with non-displaced FNF. 74% displayed osteopenia and 12% osteoporosis. 17% of the men and 38% of the women had sarcopenia.Interpretation: The majority of patients less than 70 years of age with a FNF treated with IF, had normal functional tests, muscle strength and a good hip function ten years post-operatively. However, one in ten had osteoporosis, and one third was sarcopenic which indicate the importance of encouraging regular muscle preserving resistance training after hip fracture.(c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

This qualitative study aims to explore how fourth-year medical students on the surgery course perceived a clinical anatomy workshop organised by near-peer student teachers in partnership with faculty.Forty-seven medical students participated in a workshop on clinical anatomy in the dissection laboratory. A voluntary response sampling method was used. The students' perceptions of the workshop were explored through a thematic content analysis of transcribed, semi-structured group interviews and written comments.A majority of the students had not revisited the dissection laboratory since their second year, and all students described the workshop as a unique opportunity to vertically integrate anatomical knowledge. Four main themes were identified as most valuable for the students' learning experience, namely that the workshop 1) was taught by knowledgeable and friendly near-peer tutors (NPTs), 2) consisted of highly relevant anatomical content, 3) offered a hands-on experience of cadavers in the dissection laboratory, and 4) was taught in a focused session in the middle of the surgery course. This study shows how hands-on workshops in clinical anatomy, developed in student-staff partnerships and taught by NPTs, can enable senior medical students to recall and vertically integrate anatomical knowledge during surgical clerkships. The results have implications for curriculum design, giving voice to senior students' wishes for spaced repetition and vertical integration of pre-clinical anatomy knowledge during their clinical training. Moreover, this study may inspire other students and faculty to develop similar near-peer teaching activities through student-staff partnerships.

BACKGROUND AND PURPOSE A femoral neck fracture (FNF) may have long term effects on the patient's health related quality of life (HRQoL) and mortality, especially in patients younger than 70 years. These long-term effects are unknown since most studies have a short follow-up. The aim of this study was to investigate self-assessed hip function, HRQoL and factors associated with 10-years mortality after a FNF. PATIENTS AND METHODS A prospective multicenter study with a 10-year follow-up of patients aged 20-69 years with a displaced and non-displaced FNF treated with closed reduction and internal fixation. The self-administered questionnaires EuroQol 5 Dimension (EQ-5D) and Hip Disability Outcome Score (HOOS) were used. Results of EQ-5D and HOOS was compared to sex and age matched general population data of Sweden. All patients that were deceased had their death date recorded. Factors associated with mortality were assessed by regression analysis of the baseline data including age, gender, harmful alcohol consumption according to AUDIT, co-morbidity measured by ASA-grade, body mass index, osteoporosis measured by dual energy x-ray absorptiometry (DXA) and smoking. Prevalence of co-morbidities and smoking was compared to general population data. RESULTS From initial 182 included patients, 55 were deceased at 10-year follow-up, 4 were deregistered from public record and 35 declined participations. A total of 88 patients participated through self-administrated questionnaires. There were no significant differences in HOOS between gender and fracture type and the results were equivalent to general population data. The EQ-5D continued to improve compared to a 24-month follow-up (p = 0.006) but did not recover to pre-fracture level (p

Background:A lateral patellar dislocation (LPD) is the most common traumatic knee injury with hemarthrosis in children. The redislocation rate is high. Varying operative and nonoperative treatments have been advocated with no consensus on the best treatment.Purpose:(1) To evaluate if arthroscopic-assisted repair of the medial patellofemoral ligament (MPFL) in patients with an acute first-time traumatic LPD would reduce the recurrence rate and offer better objective/subjective knee function compared with a knee brace without repair. (2) To study the presence of anatomic patellar instability risk factors (APIFs) and their association with a redislocation.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:This was a prospective series of 74 skeletally immature patients aged 9 to 14 years (38 girls and 36 boys; mean age, 13.1 years) with a first-time traumatic LPD, with clinical examinations, radiographs, magnetic resonance imaging, and diagnostic arthroscopic surgery performed within 2 weeks of the index injury. The child was randomized to either (1) a knee brace (KB group) for 4 weeks and physical therapy or (2) arthroscopic-assisted repair (R group) of the MPFL with anchors, 4 weeks with a soft cast splint, and physical therapy. The follow-up time was 2 years.Results:The redislocation rate was significantly lower in the R group than in the KB group at final follow-up: 8 patients (22%) versus 16 patients (43%), respectively ( P = .047). The Knee injury and Osteoarthritis Outcome Score for children sport/play and quality of life subscales had lower scores in the R group compared with the KB group; the significant differences were among those with redislocations. The mean Kujala score was excellent in the KB group (95.9) and good in the R group (90.9). An impaired Limb Symmetry Index (median, 83%) for concentric quadriceps torque at 90 deg/s was found only in the R group. Eighty-one percent of the study patients had ≥2 APIFs. Trochlear dysplasia (trochlear depth Conclusion:Operative repair of an MPFL injury in the acute phase in skeletally immature children with a primary traumatic LPD significantly reduced the redislocation rate but did not improve subjective or objective knee function compared with a knee brace without repair. The majority of the patients in both groups were satisfied with their knee function. There was a high representation of APIFs, which needs to be considered when evaluating the risk of redislocations.Registration:ISRCTN 39959729 (Current Controlled Trials).

Background and purpose Prospective studies on patient related outcome in patients Patients and methods 182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations. Results At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p Interpretation Two thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.

Mattias Hildén, Per Wretenberg, Wilhelmina Ekström Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Stockholm, Sweden Purpose: The Physiological and Operation Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and P (Portsmouth)-POSSUM predict the risks of complications and mortality 30 days after surgery. The purpose of this study was to evaluate the POSSUM and P-POSSUM scoring systems in patients who underwent surgery for a total hip or knee replacement. Patients and methods: A total of 227 patients with an elective primary total hip or knee replacement were included. The predicted postoperative morbidity was analyzed in these patients and compared with the observed value 30 days after surgery. Logistic regression analysis was used to assess the correlation of variables and outcome. Results: The number of patients undergoing total hip or knee replacement was equally distributed with a mean age of 66.4±12.5 years; 57% of patients were females. Postoperative complications occurred in 49 patients, and POSSUM predicted 49 cases with an observed-over-expected ratio of 1.0. The average total POSSUM score was 27.4±4.4 in patients with complications and 26.8±3.5 in patients without complications (P=0.340). Wound infection (n=18), urinary tract infection (n=7), and pulmonary embolus (n=5) were the most common complications. The operation magnitude variable had the highest mean POSSUM score making it the most relevant variable. Age and blood loss and echocardiogram had the largest variance among the assessed variables. Conclusion: POSSUM accurately predicted morbidities in patients undergoing elective primary total hip or knee replacement. The risk for wound infection, urinary retention, and pulmonary embolus should be considered during hospitalization. The computerized POSSUM system provides case-mix-adjusted morbidity predictions for groups and, hence, serves as a useful tool for surgical audits and large-scale benchmarking. Keywords: physical status, operation severity, case-mix, prediction, total joint replacement

Background and purpose The recommended treatment of displaced femoral neck fractures (FNF) in patients younger than 70 years of age is fracture reduction and internal fixation (IF). The incidence of re-operation due to nonunion (NU) or avascular necrosis (AVN) has been reported to be between 20–30%. Knowledge of possible predisposing factors needs to be elucidated. The primary aim of this study was to identify factors associated with a major re-operation due to NU or AVN in patients Patients and methods 128 patients, 20–69 years with a FNF treated with IF. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Logistic regression analysis was used to identify factors associated with re-operation due to NU or AVN. Results The re-operation rate due to NU or AVN was 6%, 16% and 28% at 4, 12 and 24 months respectively. Patients with low BMD was more likely to be re-operated than those with normal BMD, OR 5.5, CI (95%) 1.15–26.8, and those with a high alcohol consumption had 3.2 times higher odds to be re-operated due to NU or AVN, CI (95%) 1.16–8.76. Interpretation In more than two thirds (83/120) of the patients the fracture healed after one operation. Moreover, a low BMD and high alcohol consumption were related to a major re-operation. These results suggest that only age as a sole variable for choosing the type of surgical treatment may not be rational.

Background Reduced bone mineral density (BMD) together with muscle wasting and dysfunction, that is sarcopenia, emerges as a risk factor for hip fracture. The aim of this study was to examine body composition and BMD and their relationship with trauma mechanisms in young and middle-aged patients with femoral neck fracture. Materials and methods Altogether, 185 patients with femoral neck fracture aged 20-69 were included. BMD, body composition and fat-free mass index (FFMI) were determined by dual-X-ray absorptiometry (DXA), and trauma mechanisms were registered. Results Ninety per cent of the whole study population had a femoral neck BMD below the mean for age. In the young patients (

Background/Aim New surgical procedures, early operation and medical optimisation in patients with hip fracture have shown positive results on length of hospital stay. Our aims were to investigate whether patient empowerment along with an individually designed, postoperative rehabilitation programme could reduce length of hospital stay and whether the patients would have better chances to return to their previous living. Design/Method Patients were recruited during a 12-month period 2009–2010, with an intervention group treated with an individually designed, postoperative rehabilitation programme and a control group treated in a traditional way according to the hospitals routines. Final assessment was performed 4 month after surgery. The postoperative programme for the intervention group consisted of four standardised care tracks adapted individually for the patients. Assessments of Activity of Daily Living, American Society of Anesthesiologists classification of medical disease status and Short Portable Mental Status Questionnaire and living conditions were used to determine which care track was most appropriate. The patients were cared for with focus of empowerment in their rehabilitation. Results The study involved 503 hip fracture patients, 285 patients in the intervention group and 218 patients in the control group. The mean length of stay was 4 days shorter in the intervention group than in the control group (p = 0.04). Varied only to a small extent between the age groups in the intervention group and was greater between the age groups in the control. Patients in the intervention group returned to their previous living in 90% compared with 80% in the control group (p

Introduction Diabetes mellitus confers an increased risk of hip fractures. There is a limited knowledge of how the outcome after a hip fracture in patients with diabetes affect Health Related Quality of Life (HRQoL). The primary aim of this study was to evaluate HRQoL. Secondary aims were reoperation rate, complications and functions in patients with diabetes followed for 2 years after a hip fracture. Materials and methods Out of 2133 patients diabetes was present in 234 patients (11%). Main outcome measurements were HRQoL evaluated with EuroQoL 5-D index score, reoperation rate, surgical and medical complications, function as walking ability, daily activities, living condition and pain. Results Preoperatively, patients with diabetes mellitus had more pain ( p = 0.044), co-morbidities, reduced health status ( p = 0.001) and more often used a walking frame ( p = 0.014) than patients without diabetes, whereas Katz ADL index, cognition and body mass index did not differ. There was no difference in fracture type, surgical method or reoperation between the two groups or between patients with insulin treated or oral treated diabetes. The EQ-5D index score decreased from 0.64 at admission to 0.45 at 4 months, 0.49 at 12 months and 0.51 at 24 months with similar results for patients with and without diabetes. During the first postoperative year there was not more medical complications among patients with diabetes, however cardiac ( p = 0.023) and renal failure ( p = 0.032) were more frequent in patients with diabetes at 24 months. Patients with diabetes more often had severe hip pain at 4 months ( p = 0.031). At 12 months more diabetic patients were living independently ( p = 0.034). There was no difference in walking ability, ADL and living condition between the groups at 24 months. Conclusion The findings of this study indicate that patients with diabetes mellitus had more pain, co-morbidities, reduced health status preoperatively than patients without diabetes. Hip fracture patients with diabetes mellitus have more hip pain at 4 months. Cardiac and renal failure was more frequent in patients with diabetes at 24 months but otherwise we found a comparable re-operation rate, function and deterioration of Health Related Quality of Life as patients without diabetes within 2 years after a hip fracture.

Prospective studies on patient related outcome in patients70years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20-69years old patients with a FNF treated with internal fixation.182 patients, 20-69years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations.At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p=0.15). Of the patients with displaced fracture (n=120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n=50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5DTwo thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.

Background EQ-5D and SF-36 are two questionnaires used to measure health related quality of life (HRQoL). The responsiveness of these instruments has previously been evaluated in elderly populations with hip fracture but not in a younger population. The purpose was to evaluate the responsiveness of SF-36 and EQ-5D in a younger population with femoral neck fracture. Methods 182 patients aged 20–69 were consecutively included. HRQoL was measured by EQ-5D and SF-36 at 4, 12 and 24 months. Pain and function were measured by Harris Hip Score (HHS) on the same occasions. The responsiveness of EQ-5D and SF-36 was evaluated by calculation of two effect sizes; standardized effect size (SES) and standardized response mean (SRM), and by analysing how changes in score correlated to changes in function and subjective state of health. External responsiveness was also evaluated by calculating receiver operating characteristic curve and area under the curve. Results SES was large at four months for both EQ-5D and SF-36 (1.09 and 0.83 respectively) and moderate at the 12- and 24-month follow-ups. The correlation between changes (4–24 months) in HHS and changes in HRQoL were 0.44 for EQ-5D and 0.37 for SF-36. EQ-5D and SF-36 were both more sensitive than HHS in their ability to predict subjective improvements after a hip fracture. Conclusions The effect sizes and the ability to follow and predict the external standard indicates that both EQ-5D and SF-36 have good internal and external responsiveness in this younger population with femoral neck fracture. The generic HRQoL questionnaires were superior to a hip-specific instrument in predicting the patients’ subjective feelings of an improved state of health. EQ-5D is simple to administer and shows similar responsiveness as SF-36 and may be sufficient to use as an outcome measure in clinical trials.

Background The surgical treatment of pathological subtrochanteric fractures has been associated with technical difficulties and frequent failures. We analyzed survival, risk factors for death, and outcome after surgical treatment. Methods The study group consisted of 194 patients with pathological subtrochanteric femur fractures operated during 1999–2009. Cox multiple-regression analysis was performed to study risk factors and results were expressed as hazard ratios (HR). We included a control group with non-pathological subtrochanteric fractures (n = 87) for comparison. Results The median age at surgery was 68 (29–96) years in the study group and 82 (66–101) in the controls. The 1-year survival rate after surgery was 33% (95% CI: 26–40) in the study group and 85% (79–93) in the controls. In the study group, the risk of death after surgery was increased for patients ≥65 years of age (HR 1.5, 95% CI: 1.1–2.1), with a moderate (HR 2.2, 1.5–3.4) and poor (HR 2.9, 1.6–5.2) Karnofsky score, with visceral metastases (HR 1.6, 1.1–2.3), and perioperative hemoglobin levels

Background The subtrochanteric fracture constitutes approximately 5–10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures. Objective To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL. Setting Four university hospitals. Design A prospective cohort study with a 2-year follow-up. Patients and methods Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5D index score). Results The EQ-5D index score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months. Conclusions A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs).

Background: A lateral patellar dislocation (LPD) is the most common knee injury in children with traumatic knee hemarthrosis. The medial patellofemoral ligament (MPFL), the important passive stabilizer against LPDs, is injured in more than 90% of cases. The MPFL injury pattern is most often defined in adults or in mixed-age populations. The injury pattern in the skeletally immature patient may be different. Purpose: To describe MPFL injuries in the skeletally immature patient by magnetic resonance imaging (MRI), and to compare the results with the injury pattern found at arthroscopic surgery. Study Design: Case series; Level of evidence, 4. Methods: This was a prospective series of patients aged 9 to 14 years with acute, first-time traumatic LPDs in whom clinical examinations, radiographs, MRI, and arthroscopic surgery were performed within 2 weeks from the index injury. The MPFL injury was divided into 3 different groups according to the location: patellar site, femoral site, or multifocal. The MPFL injury site was confirmed on MRI by soft tissue edema. The length of the MPFL injury at the patellar site was measured at arthroscopic surgery, and those ≥2 cm were defined as total ruptures. Results: A total of 74 patients (40 girls and 34 boys; mean age, 13.1 years) were included; 73 patients (99%) had an MPFL injury according to MRI and arthroscopic surgery. The MRI scans showed an isolated MPFL injury at the patellar attachment site in 44 of 74 patients (60%), a multifocal injury in 26 patients (35%), an injury at the femoral site in 3 patients (4%), and no injury in 1 patient (1%). Arthroscopic surgery disclosed an isolated MPFL injury at the patellar site in 60 of 74 patients (81%) and a multifocal injury in 13 patients (18%); the MPFL injury at the patellar site was a total rupture in 49 patients (66%). Edema at the patellar attachment site on MRI was proven to be an MPFL rupture at the same site at arthroscopic surgery in 99% of the patients. A patellar-based injury, isolated or as part of a multifocal injury, was present on MRI in 95% (n = 70) of the patients, with a false-negative rate of 5% (n = 4) of patients compared with arthroscopic surgery. Conclusion: Skeletally immature children are more prone to sustaining an MPFL injury at the patellar attachment site. Arthroscopic surgery and MRI complement each other in the investigation of MPFL injuries.

Background The catabolic state that follows hip fracture contributes to loss of muscle mass and strength, that is sarcopenia, which impacts functional ability and health-related quality of life. Measures to prevent such long-term postoperative consequences are of important concern. The aim of this study was to evaluate the combined effects of protein-rich nutritional supplementation and bisphosphonate on body composition, handgrip strength and health-related quality of life following hip fracture. Methods The study included 79 men and women with hip fracture, mean age 79 years (SD 9), without severe cognitive impairment, who were ambulatory and living independently before fracture. Patients were randomized postoperatively to receive liquid supplementation that provided 40 g of protein and 600 kcal daily for six months after the fracture, in addition to bisphosphonates once weekly for 12 months (group N, n = 26), or bisphosphonates alone once weekly for 12 months (group B, n = 28). All patients, including the controls (group C, n = 25) received calcium 1 g and vitamin D3 800 IU daily. Body composition as measured by dual-energy X-ray absorptiometry (DXA), handgrip strength (HGS) and health-related quality of life (HRQoL) were registered at baseline, six and 12 months postoperatively. Results There were no differences among the groups regarding change in fat-free mass index (FFMI), HGS, or HRQoL during the study year. Intra-group analyses showed improvement of HGS between baseline and six months in the N group (P = 0.04). HRQoL decreased during the first year in the C and B groups (P = 0.03 and P = 0.01, respectively) but not in the nutritional supplementation N group (P = 0.22). Conclusions Protein-rich nutritional supplementation was unable to preserve FFMI more effectively than vitamin D and calcium alone, or combined with bisphosphonate, in this relatively healthy group of hip fracture patients. However, trends toward positive effects on both HGS and HRQoL were observed following nutritional supplementation. Trial registration Clinicaltrials.gov NCT01950169 (Date of registration 23 Sept 2013). Electronic supplementary material The online version of this article (doi:10.1186/s12877-015-0144-7) contains supplementary material, which is available to authorized users.

Wilhelmina Ekström,1 Bodil Samuelsson,2 Sari Ponzer,3 Tommy Cederholm,4,5 Karl-Göran Thorngren,6 Margareta Hedström7 1Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, 2Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 3Department of Clinical Science and Education, Section of Orthopaedics, Karolinska Institutet, Södersjukhuset, Stockholm, 4Department of Public Health and Caring Sciences, 5Department of Geriatrics, Uppsala University, Uppsala University Hospital, Uppsala, 6Department of Clinical Sciences, Lund, Orthopaedics, Lund University, Lund, 7Department of Orthopaedics, Institute of Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Huddinge, Stockholm, Sweden Objectives: To evaluate potential sex differences and other factors associated with complications within 4 months after a hip fracture.Methods: A total of 1,915 patients ≥65 years (480 men) with hip fracture were consecutively included in a prospective multicenter cohort study. A review of medical records and patient interviews according to a study protocol based on the Standardized Audit of Hip Fractures in Europe (SAHFE, RIKSHÖFT) was performed. Sex differences in comorbidity according to the American Society of Anesthesiologists score and complications 4 months after a hip fracture were registered. Multivariate logistic regression analysis was performed to identify factors related to complications.Results: Male sex was associated with worse general health according to the American Society of Anesthesiologists classification (P=0.005) and with more comorbidities (P

Background: Hemarthrosis after acute knee trauma is a sign of a potentially serious knee injury. Few studies have described the epidemiology and detailed injury spectrum of acute knee injuries in a general pediatric population. Purpose: To document the current injury spectrum of acute knee injuries with hemarthrosis in children aged 9 to 14 years and to describe the distribution of sex, age at injury, type of activity, and activity frequency in this population. Study Design: Descriptive epidemiology study. Methods: All patients in the Stockholm County area aged 9 to 14 years who suffered acute knee trauma with hemarthrosis were referred to Astrid Lindgren Children’s Hospital, Karolinska University Hospital, from September 2011 to April 2012. The patients underwent clinical examination, radiography, and magnetic resonance imaging (MRI). The type of activity when injured, regular sports activity/frequency, and patient sex and age were registered. The diagnoses were classified into minor and serious injuries. Results: The study included 117 patients (47 girls and 70 boys; mean age, 13.2 years). Seventy percent had a serious knee injury. Lateral patellar dislocations, anterior cruciate ligament ruptures, and anterior tibial spine fractures were the most common injuries, with an incidence of 0.6, 0.2, and 0.1 per 1000 children, respectively. The sex distribution was equal up to age 13 years; twice as many boys were seen at the age of 14 years. The majority of injuries occurred during sports. Forty-six patients (39%) had radiographs without a bony injury but with a serious injury confirmed on MRI. Conclusion: Seventy percent of the patients aged 9 to 14 years with traumatic knee hemarthrosis had a serious intra-articular injury that needed specific medical attention. Fifty-six percent of these patients had no visible injury on plain radiographs. Physicians who treat this group of patients should consider MRI to establish the diagnosis when there is no or minimal radiographic findings. The most common serious knee injury was a lateral patellar dislocation. This should be taken into consideration to improve prevention strategies and treatment algorithms in pediatric knee injuries.

A 1-year-old boy had been treated for a respiratory syncytial virus infection at the age of 4 weeks; otherwise his past medical history was unremarkable. Starting at the age of 7 months, the boy ha...

Background and purpose There have been few prospective studies examining young and middle-aged patients with hip fracture. We therefore investigated background data, risk factors, and the trauma mechanism in young and middle-aged patients with femoral neck fracture. Patients and methods 185 patients, 27 young (20–49 years old) and 158 middle-aged (50–69 years old) were prospectively included in a multicenter study lasting 3 years. Background data and risk factors for osteoporosis and fracture were obtained, and the type of injury was classified as low-energy trauma, high-energy trauma, or sports injury. Results In the young age group, the fracture occurred because of low-energy trauma in two-fifths of patients and because of sport injury in two-fifths of patients. The rest occurred because of high-energy trauma. The corresponding proportions for the middle-aged group were four-fifths, one tenth, and one tenth (p < 0.001). There was a higher proportion of men (19/27) in the young group than in the middle-aged group (69/158) (p = 0.001). One fifth of the young patients were smokers as compared to two-fifths in the middle-age group (p = 0.04). One quarter of the patients reported high-volume alcohol drinking, with no difference between the two groups. Furthermore, three-quarters of the young patients and four-fifths of the middle-aged patients had one or more risk factors for osteoporosis and fracture. Interpretation A minority of patients in each age group had high-energy trauma as the cause of their femoral neck fracture. Lifestyle factors and other non-trauma-related risk factors appear to have been important contributors to the occurrence of femoral neck fracture in both age groups.

The surgical treatment of pathological subtrochanteric fractures has been associated with technical difficulties and frequent failures. We analyzed survival, risk factors for death, and outcome after surgical treatment.The study group consisted of 194 patients with pathological subtrochanteric femur fractures operated during 1999-2009. Cox multiple-regression analysis was performed to study risk factors and results were expressed as hazard ratios (HR). We included a control group with non-pathological subtrochanteric fractures (n = 87) for comparison.The median age at surgery was 68 (29-96) years in the study group and 82 (66-101) in the controls. The 1-year survival rate after surgery was 33% (95% CI: 26-40) in the study group and 85% (79-93) in the controls. In the study group, the risk of death after surgery was increased for patients ≥65 years of age (HR 1.5, 95% CI: 1.1-2.1), with a moderate (HR 2.2, 1.5-3.4) and poor (HR 2.9, 1.6-5.2) Karnofsky score, with visceral metastases (HR 1.6, 1.1-2.3), and perioperative hemoglobin levels100 g/L (HR 2.2, 1.3-3.7). In patients with pathological fractures, there was no statistically significant difference concerning reoperation rates comparing intramedullary nails (9%) with endoprostheses (6%; P = 0.3).Surgery for pathological subtrochanteric femur fractures is a relatively safe and effective procedure.

The outcome for many patients with a hip fracture remains poor. The aim of the present study was to investigate whether the timing of surgery in such patients could influence the short-term clinical outcome.We included 850 consecutive patients with a hip fracture who were admitted to the hospital during one year in a prospective study. Three cutoff limits for a comparison of early and late operation were defined. The outcome (the ability to return to independent living, risk for the development of pressure ulcers, length of the hospital stay, and mortality rate) for patients who had an operation within twenty-four, thirty-six, and forty-eight hours was compared with the outcome for those who had an operation at a later time.Patients who had the operation more than thirty-six and forty-eight hours after admission were less likely to return to independent living within four months (odds ratio, 0.44 and 0.33, respectively), whereas there was no significant difference with use of the twenty-four-hour cutoff limit. The incidence of pressure ulcers in the groups that had the operation later was increased at all three cutoff limits (a delay of more than twenty-four hours, more than thirty-six hours, and more than forty-eight hours) (odds ratio, 2.19, 3.42, and 4.34, respectively). The length of hospitalization was also increased in the groups that had the later operation (median, fourteen compared with eighteen days, fifteen compared with nineteen days, and fifteen compared with twenty-one days, respectively) (p0.001 for all comparisons). The importance of surgical timing remained significant after adjusting for several possible confounders (p0.05).Early compared with late operative treatment of patients with a hip fracture is associated with an improved ability to return to independent living, a reduced risk for the development of pressure ulcers, and a shortened hospital stay.

The subtrochanteric fracture constitutes approximately 5-10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures.To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.Four university hospitals.A prospective cohort study with a 2-year follow-up.Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5D(index) score).The EQ-5D(index) score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months.A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs).

Background: Hip fracture patients are reported to have an increased mortality rate compared to the general population. In order to be able to reduce the morbidity and mortality after a hip fracture, our efforts to identify the patients at risk already upon admission to the hospital need to be increased. For such a risk assessment, robust, validated, and reproducible criteria are mandatory. Objective: To determine preoperative factors associated with mortality and to evaluate the combined use of the American Society of Anesthesiologists (ASA) and the Short Portable Mental Status Questionnaire (SPMSQ) to identify patients with an increased mortality rate and to create a predictive model to assess the mortality risk after hip fracture surgery. Methods: A total of 1,944 consecutive patients aged 66 years or older admitted for a hip fracture were included in a prospective cohort study with a 24-month follow-up. The patients were assessed with regard to gender, age, type of hip fracture, smoking habits, comorbidities, general physical health according to the ASA classification, and cognitive function according to the SPMSQ. A higher ASA score indicates an increasingly severe systemic disease and a lower SPMSQ score indicates an increasingly severe cognitive dysfunction. We used Cox proportional hazard models and classification trees to identify the factors associated with mortality. The predictive model was created based on factors that were significantly associated with death and all readily accessible upon admission. Results: The mortality rate during the acute hospitalization period was 4%, at 4 months 16%, and at 24 months 38%. The most prominent factors associated with mortality were high ASA scores, low SPMSQ scores, high age and male gender. The SPMSQ score provided additional information about the survival time, compared to when the ASA score was used alone. Conclusion: The combined use of the ASA classification for assessing physical health and the SPMSQ for assessing cognitive function effectively identified hip fracture patients with an increased mortality rate. We present a predictive model including age, gender, ASA, and SPMSQ that can be used to assess the mortality risk after hip fracture surgery.

The aim of this study was to report the long-term outcome for patients with stable trochanteric fractures, especially regarding the health-related quality of life (HRQoL).A prospective cohort study with a 2-year follow-up.Four university hospitals.One hundred forty-eight consecutive patients with stable trochanteric fractures, that is, a 2-part fracture (J-M 1 and 2) according to the Jensen-Michaelsen classification, treated with a sliding hip screw.Mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function, and HRQoL assessed with the EuroQol-5D (EQ-5D index score).The 2-year mortality rate was 29%. The reoperation rate was 3%. At the final follow-up, 81% of the patients reported no or only limited pain at the hip, 55% had regained their prefracture walking ability, and 66% their prefracture level of ADL function. The EQ-5D index score decreased from 0.69 before the fracture to 0.57 at 4 months, 0.59 at 12 months, and 0.66 at 24 months.Besides the expected mortality rate, the results of the study confirm a low reoperation rate and a good outcome regarding pain at the hip and only limited deterioration in HRQoL after a stable trochanteric fracture. However, a considerable number of the patients experienced deterioration in their walking ability and ADL function. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life years.