Session 15: Infection/Amputation and Trauma II
Fredag d. 28. oktober
9:00-10:30
Lokale: Stockholm / Copenhagen
Chairmen: Christian Wied / Rasmus Elsøe
Morten Tange Kristensen, Annie Østergaard Nielsen, Peter Gebuhr
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital Hvidovre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Early in-hospital rehabilitation following major lower limb amputation is mainly focused at patient’s independence in basic mobility activities. Thus, an easily applicable measure for daily assessment of these skills, planning of training, and communication between health care professionals is of great importance.
Purpose / Aim of Study: To develop and examine inter-rater reliability of the Basic Amputee Mobility Score (BAMS) in patients with a lower limb amputation.
Materials and Methods: Four essential basic amputee activities; 1.supine in bed to sitting on the side of the bed and return, 2.bed to chair transfer and return, 3.indoor wheelchair manoeuvring, and 4. One-leg sit-to-stand-to-sit from a chair with arms, were chosen through consensus meetings with experienced amputee physical therapists. Each activity is scored from 0-2 (0=not able to, 1=able to with assistance, and 2=independent), and cumulated to a daily score of 0-8. Inter-rater reliability and agreement was established by 1 experienced and 1 un-experienced user of BAMS, using standardized instructions. Raters were blinded to each others ratings and in charge of sessions in a randomized order.
Findings / Results: Assessments were conducted within the first week of a major dysvascular lower limb amputation in 30 Patients. The mean (SD) of BAMS was 5.6 (2.3) points, while the ICC1.1, the standard error of measurement, and the minimal detectable change were 0.98 (95%CI, 0.96-0.99), 0.32 and 0.89 points, respectively. No systematic between-rater bias was seen (p=0.3). BAMS is fully implemented in the capital region.
Conclusions: The inter-rater reliability of BAMS is excellent, and changes of 1 point (group and individual level) indicate a real change in BAMS. We suggest the score be further used for communication between different groups of health care professionals and settings.
Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital Hvidovre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Early in-hospital rehabilitation following major lower limb amputation is mainly focused at patient’s independence in basic mobility activities. Thus, an easily applicable measure for daily assessment of these skills, planning of training, and communication between health care professionals is of great importance.
Purpose / Aim of Study: To develop and examine inter-rater reliability of the Basic Amputee Mobility Score (BAMS) in patients with a lower limb amputation.
Materials and Methods: Four essential basic amputee activities; 1.supine in bed to sitting on the side of the bed and return, 2.bed to chair transfer and return, 3.indoor wheelchair manoeuvring, and 4. One-leg sit-to-stand-to-sit from a chair with arms, were chosen through consensus meetings with experienced amputee physical therapists. Each activity is scored from 0-2 (0=not able to, 1=able to with assistance, and 2=independent), and cumulated to a daily score of 0-8. Inter-rater reliability and agreement was established by 1 experienced and 1 un-experienced user of BAMS, using standardized instructions. Raters were blinded to each others ratings and in charge of sessions in a randomized order.
Findings / Results: Assessments were conducted within the first week of a major dysvascular lower limb amputation in 30 Patients. The mean (SD) of BAMS was 5.6 (2.3) points, while the ICC1.1, the standard error of measurement, and the minimal detectable change were 0.98 (95%CI, 0.96-0.99), 0.32 and 0.89 points, respectively. No systematic between-rater bias was seen (p=0.3). BAMS is fully implemented in the capital region.
Conclusions: The inter-rater reliability of BAMS is excellent, and changes of 1 point (group and individual level) indicate a real change in BAMS. We suggest the score be further used for communication between different groups of health care professionals and settings.
Alma B Pedersen, Christian F Christiansen, Henrik Gammelager , Johnny Kahlert, Henrik Toft Sørensen
of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital
Background: Fractures of the hip represent a major worldwide public health problem, associated with significant mortality.
Purpose / Aim of Study: We examined risk of developing acute renal failure and the associated mortality among patients aged > 65 years undergoing surgery for a fracture of the hip.
Materials and Methods: We used medical databases to identify patients who underwent surgical treatment for a fracture of the hip in Northern Denmark between 2005 and 2011. Acute renal failure (ARF) was classified as stage 1, 2, and 3 according to the Kidney Disease Improving Global Outcome criteria. We computed the risk of developing ARF within five days after surgery with death as a competing risk, and the short-term (six to 30 days post-operatively) and long-term mortality (31 days to 365 days post-operatively). We calculated adjusted hazard ratios (HRs) for death with 95% confidence intervals (CIs).
Findings / Results: Among 13,529 patients who sustained a fracture of the hip, 1,717 (12.7%) developed ARF post- operatively, including 1,218 (9.0%) with stage 1, 364 (2.7%) with stage 2, and 135 (1.0%) with stage 3 renal failure. The short-term mortality was 15.9% and 5.6% for patients with and without ARF, respectively (HR 2.8, 95% CI 2.4 to 3.2). The long-term mortality was 25.0% and 18.3% for those with and without ARF, respectively (HR 1.3, 95% CI 1.2 to 1.5). The mortality was higher in patients with an increased severity of renal failure.
Conclusions: ARF is a common complication of surgery in elderly patients who sustain a fracture of the hip, and is associated with increased mortality up to one year after surgery despite adjustment for coexisting comorbidity and medication before surgery. Even small change in renal function within five days of surgery for a fracture of the hip has substantial implication on mortality up to one year post- operatively.
of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital; of Clinical Epidemiology, Aarhus University Hospital
Background: Fractures of the hip represent a major worldwide public health problem, associated with significant mortality.
Purpose / Aim of Study: We examined risk of developing acute renal failure and the associated mortality among patients aged > 65 years undergoing surgery for a fracture of the hip.
Materials and Methods: We used medical databases to identify patients who underwent surgical treatment for a fracture of the hip in Northern Denmark between 2005 and 2011. Acute renal failure (ARF) was classified as stage 1, 2, and 3 according to the Kidney Disease Improving Global Outcome criteria. We computed the risk of developing ARF within five days after surgery with death as a competing risk, and the short-term (six to 30 days post-operatively) and long-term mortality (31 days to 365 days post-operatively). We calculated adjusted hazard ratios (HRs) for death with 95% confidence intervals (CIs).
Findings / Results: Among 13,529 patients who sustained a fracture of the hip, 1,717 (12.7%) developed ARF post- operatively, including 1,218 (9.0%) with stage 1, 364 (2.7%) with stage 2, and 135 (1.0%) with stage 3 renal failure. The short-term mortality was 15.9% and 5.6% for patients with and without ARF, respectively (HR 2.8, 95% CI 2.4 to 3.2). The long-term mortality was 25.0% and 18.3% for those with and without ARF, respectively (HR 1.3, 95% CI 1.2 to 1.5). The mortality was higher in patients with an increased severity of renal failure.
Conclusions: ARF is a common complication of surgery in elderly patients who sustain a fracture of the hip, and is associated with increased mortality up to one year after surgery despite adjustment for coexisting comorbidity and medication before surgery. Even small change in renal function within five days of surgery for a fracture of the hip has substantial implication on mortality up to one year post- operatively.
Anders Thorsmark Høj, Lars Henrik Frich, Ole Maagaard, Søren Overgaard, Søren Torp-Pedersen
Holbæk sygehus, department of orthopedic Surgery and Traumatology, OUH/ den ortopæd kirurgiske forskningsenhed; Department of Orthopedic Surgery and Traumatology, OUH; Holbæk sygehus, department of orthopedic Surgery and Traumatology, Holbæk; Department of Orthopedic Surgery and Traumatology, OUH; department of radiology , Glostrup hospital
Background: Clavicular bone shortening is a relative indication for operative treatment of acute clavicular fractures. Although it is a clinically accepted indication, it is still scientifically contested. The reason for this is multifactorial. However, as different measurement methods exist ( methods using fragment overlap or side difference) and the possible bias of radiographic magnification; there is a possibility that differences in methodology and magnification bias could have caused these scientific differences. We wanted to investigate the literature for differences in methodologies used and therefore designed a systematic review.
Purpose / Aim of Study: Our objectives were (i) review studies on bone shortening for differences in methodology specifically regarding measurement method used. (ii) Estimate radiographic magnification in studies.
Materials and Methods: To study methodological differences (i) we found 13 studies. For the estimation of radiographic magnification bias, we found (ii) 9 anatomical reference studies and five radiographic index studies.
Findings / Results: We found that (i) measurement method used highly effected the study’s results and conclusions. Studies showing adverse effects of shortening had mostly used the fragment overlap method whereas studies that found shortening to be not harmful had used the side difference method. We found that the majority of studies had highly underestimated the bias of radiographic magnification and (ii) bias was estimated to be between 10-25% if not adjusted for magnification.
Conclusions: In conclusion, the scientific controversy of bone shortening seems to be because of differences in methodologies - especially measurement method used, and not only differences in results. Radiographic magnification is much larger cause of bias than previously thought and should routinely be adjusted for.
Holbæk sygehus, department of orthopedic Surgery and Traumatology, OUH/ den ortopæd kirurgiske forskningsenhed; Department of Orthopedic Surgery and Traumatology, OUH; Holbæk sygehus, department of orthopedic Surgery and Traumatology, Holbæk; Department of Orthopedic Surgery and Traumatology, OUH; department of radiology , Glostrup hospital
Background: Clavicular bone shortening is a relative indication for operative treatment of acute clavicular fractures. Although it is a clinically accepted indication, it is still scientifically contested. The reason for this is multifactorial. However, as different measurement methods exist ( methods using fragment overlap or side difference) and the possible bias of radiographic magnification; there is a possibility that differences in methodology and magnification bias could have caused these scientific differences. We wanted to investigate the literature for differences in methodologies used and therefore designed a systematic review.
Purpose / Aim of Study: Our objectives were (i) review studies on bone shortening for differences in methodology specifically regarding measurement method used. (ii) Estimate radiographic magnification in studies.
Materials and Methods: To study methodological differences (i) we found 13 studies. For the estimation of radiographic magnification bias, we found (ii) 9 anatomical reference studies and five radiographic index studies.
Findings / Results: We found that (i) measurement method used highly effected the study’s results and conclusions. Studies showing adverse effects of shortening had mostly used the fragment overlap method whereas studies that found shortening to be not harmful had used the side difference method. We found that the majority of studies had highly underestimated the bias of radiographic magnification and (ii) bias was estimated to be between 10-25% if not adjusted for magnification.
Conclusions: In conclusion, the scientific controversy of bone shortening seems to be because of differences in methodologies - especially measurement method used, and not only differences in results. Radiographic magnification is much larger cause of bias than previously thought and should routinely be adjusted for.
Christian Wied, Peter Toft Tengberg, Morten Tange Kristensen, Gitte Holm, Thomas Kallemose, Anders Troelsen, Nicolai Bang Foss
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre
Background: Underestimation of the actual blood loss in patients undergoing dysvascular Transfemoral Amputation (TFA) can impact negatively on outcome, in these often frail patients with very limited physiological reserves.
Purpose / Aim of Study: To estimate the Total Blood Loss (TBL) after TFA. Secondly, to evaluate the impact of blood loss and transfusions on the 30-days mortality and medical complications.
Materials and Methods: A single-center retrospective cohort study conducted from 2013 to 2015. The TBL was calculated on the fourth postoperative day, and based on the development in hemoglobin levels, transfusions, and the estimated blood volume. Hemoglobin was measured daily until the fifth post- operative day, and transfusions were given at a red blood cell (RBC) level below 9.7 g/dl.
Findings / Results: In all 81 TFA patients were studied. The TBL was calculated to a median of 964ml (IQR: 407-1521). The intraoperative blood loss (OBL) was measured to 400ml (IQR: 250-550), and the difference between TBL and OBL was 688ml (IQR: 180-1156). The patients received RBC transfusions with a median amount of 2 units per patient. Adjusted multivariable analysis showed that the TBL on average was 489 (95%CI, 38 – 940, p=0.034) ml larger in patients suffering from kidney disease prior to surgery. The TBL was not independently associated with increased 30-days mortality or medical complications, nor was transfusions above 2 units.
Conclusions: The TBL after TFA’s is significantly greater than the estimated OBL, and significantly increased if kidney disease is present prior to surgery. A high anemia vigilance seems recommendable in the perioperative period and especially after TFA surgery.
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre
Background: Underestimation of the actual blood loss in patients undergoing dysvascular Transfemoral Amputation (TFA) can impact negatively on outcome, in these often frail patients with very limited physiological reserves.
Purpose / Aim of Study: To estimate the Total Blood Loss (TBL) after TFA. Secondly, to evaluate the impact of blood loss and transfusions on the 30-days mortality and medical complications.
Materials and Methods: A single-center retrospective cohort study conducted from 2013 to 2015. The TBL was calculated on the fourth postoperative day, and based on the development in hemoglobin levels, transfusions, and the estimated blood volume. Hemoglobin was measured daily until the fifth post- operative day, and transfusions were given at a red blood cell (RBC) level below 9.7 g/dl.
Findings / Results: In all 81 TFA patients were studied. The TBL was calculated to a median of 964ml (IQR: 407-1521). The intraoperative blood loss (OBL) was measured to 400ml (IQR: 250-550), and the difference between TBL and OBL was 688ml (IQR: 180-1156). The patients received RBC transfusions with a median amount of 2 units per patient. Adjusted multivariable analysis showed that the TBL on average was 489 (95%CI, 38 – 940, p=0.034) ml larger in patients suffering from kidney disease prior to surgery. The TBL was not independently associated with increased 30-days mortality or medical complications, nor was transfusions above 2 units.
Conclusions: The TBL after TFA’s is significantly greater than the estimated OBL, and significantly increased if kidney disease is present prior to surgery. A high anemia vigilance seems recommendable in the perioperative period and especially after TFA surgery.
Jan Arnholtz Overgaard, Thomas Kallemose, Morten Tange Kristensen
Dept. of Rehabilitation, Municipality of Lolland, Maribo; Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C); Dept. of Orthopaedic Surgery, Clinical Research Centre, Copenhagen University Hospital Hvidovre; Departments of Physiotherapy & Orthopaedic Surgery, Hvidovre Hospital, Copenhagen University, Copenhagen; Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C)
Background: The latest Cochrane review emphasized the need for RCTs to investigate the timing, duration, and intensity of different physiotherapy (PT) interventions in patients with hip fracture (HF). However, such studies have most often been conducted as extended programs following ceased standard PT.
Purpose / Aim of Study: To examine if 12 weeks of community-based PT with progressive strength training is more efficacious than 6 weeks in improving walking distance in patients when commenced shortly after discharge from HF surgery.
Materials and Methods: 100 community-dwelling patients with HF were included from 4 outpatient centers at a mean (SD) of 18 (5.9) days after surgery, and equally randomized in two groups, in this assessor blinded study. Both groups received functional, balance, and progressive lower limb strength training exercises, 2 times a week. The primary outcome was change in walking distance in the 6-minute walk test from baseline to the 6 months follow-up.
Findings / Results: Intention-to-treat analysis showed no significant between-group difference in the primary outcome, versus significant improvements, mean of 3.5 (95%CI; 0.8 to 6.1) seconds for the TUG in favor of the 12-week group. The fractured limb strength deficit % non-fractured was reduced with a mean of 34% in the 12-week group as compared to 24% in the 6-week group. Still, 46% of all patients had not regained their pre-fracture functional level at follow- up.
Conclusions: 12 weeks of PT with strength training was not more efficacious than 6 weeks in improving the walking distance in patients with HF, but a significant improvement was seen for the Timed Up & Go test in favor of the 12-week group. Also, the 12-week program seems superior in reducing the fractured limb strength deficit. However, almost half of all patients still experienced functional deficits after 6 months.
Dept. of Rehabilitation, Municipality of Lolland, Maribo; Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C); Dept. of Orthopaedic Surgery, Clinical Research Centre, Copenhagen University Hospital Hvidovre; Departments of Physiotherapy & Orthopaedic Surgery, Hvidovre Hospital, Copenhagen University, Copenhagen; Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C)
Background: The latest Cochrane review emphasized the need for RCTs to investigate the timing, duration, and intensity of different physiotherapy (PT) interventions in patients with hip fracture (HF). However, such studies have most often been conducted as extended programs following ceased standard PT.
Purpose / Aim of Study: To examine if 12 weeks of community-based PT with progressive strength training is more efficacious than 6 weeks in improving walking distance in patients when commenced shortly after discharge from HF surgery.
Materials and Methods: 100 community-dwelling patients with HF were included from 4 outpatient centers at a mean (SD) of 18 (5.9) days after surgery, and equally randomized in two groups, in this assessor blinded study. Both groups received functional, balance, and progressive lower limb strength training exercises, 2 times a week. The primary outcome was change in walking distance in the 6-minute walk test from baseline to the 6 months follow-up.
Findings / Results: Intention-to-treat analysis showed no significant between-group difference in the primary outcome, versus significant improvements, mean of 3.5 (95%CI; 0.8 to 6.1) seconds for the TUG in favor of the 12-week group. The fractured limb strength deficit % non-fractured was reduced with a mean of 34% in the 12-week group as compared to 24% in the 6-week group. Still, 46% of all patients had not regained their pre-fracture functional level at follow- up.
Conclusions: 12 weeks of PT with strength training was not more efficacious than 6 weeks in improving the walking distance in patients with HF, but a significant improvement was seen for the Timed Up & Go test in favor of the 12-week group. Also, the 12-week program seems superior in reducing the fractured limb strength deficit. However, almost half of all patients still experienced functional deficits after 6 months.
Pia Kjær Kristensen, Theis Muncholm Thillemann, Alma Becic Pedersen, Kjeld Søballe, Søren Paaske Johnsen
Department of Orthopedic Surgery, Horsens Regional Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology , Aarhus University Hospital
Background: Socioeconomic status influence the risk of hip fractures, but the evidence is more limited and conflicting regarding the extent to which socioeconomic status will have an impact on quality of in-hospital care received and survival after hip fracture.
Purpose / Aim of Study: We examined the association between socioeconomic status and 30-day mortality, acute readmission, quality of in-hospital care, time to surgery and length of stay.
Materials and Methods: A population-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry. We identified 25,354 patients ¡Ý65 years admitted with a hip fracture between 2010 and 2013. From Statistic Denmark we assess data on socioeconomic status for all patients including highest obtained education, family mean income, cohabiting status and ethnicity. We performed multilevel regression analysis, controlling for potential confounders.
Findings / Results: Hip fracture patients with highest education had lower 30-day mortality compared to patients with low education (7.3% vs 10.0% adjusted Odds Ratio (OR) = 0.74 (95 % confidence interval (CI) (0.63-0.88)). Highest level of family income was also associated with lower 30-day mortality (11.9% vs 13.0 % adjusted OR = 0.77, 95 % CI 0.69-0.85). Cohabiting status and ethnicity were not associated with 30-day mortality in the adjusted analysis. Furthermore patients with both high education and high income had lower risk of acute readmission (14.5% vs 16.9 % adjusted OR = 0.94, 95 % CI 0.91-0.97). Socioeconomic status was, however, not associated with quality of in-hospital care, time to surgery and length of hospital stay.
Conclusions: Higher education and higher family income was associated with substantially lower 30-day mortality, but it could not be explained by differences in the provision of care during hospitalization.
Department of Orthopedic Surgery, Horsens Regional Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology , Aarhus University Hospital
Background: Socioeconomic status influence the risk of hip fractures, but the evidence is more limited and conflicting regarding the extent to which socioeconomic status will have an impact on quality of in-hospital care received and survival after hip fracture.
Purpose / Aim of Study: We examined the association between socioeconomic status and 30-day mortality, acute readmission, quality of in-hospital care, time to surgery and length of stay.
Materials and Methods: A population-based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry. We identified 25,354 patients ¡Ý65 years admitted with a hip fracture between 2010 and 2013. From Statistic Denmark we assess data on socioeconomic status for all patients including highest obtained education, family mean income, cohabiting status and ethnicity. We performed multilevel regression analysis, controlling for potential confounders.
Findings / Results: Hip fracture patients with highest education had lower 30-day mortality compared to patients with low education (7.3% vs 10.0% adjusted Odds Ratio (OR) = 0.74 (95 % confidence interval (CI) (0.63-0.88)). Highest level of family income was also associated with lower 30-day mortality (11.9% vs 13.0 % adjusted OR = 0.77, 95 % CI 0.69-0.85). Cohabiting status and ethnicity were not associated with 30-day mortality in the adjusted analysis. Furthermore patients with both high education and high income had lower risk of acute readmission (14.5% vs 16.9 % adjusted OR = 0.94, 95 % CI 0.91-0.97). Socioeconomic status was, however, not associated with quality of in-hospital care, time to surgery and length of hospital stay.
Conclusions: Higher education and higher family income was associated with substantially lower 30-day mortality, but it could not be explained by differences in the provision of care during hospitalization.
Pia Kjær Kristensen, Anil Mor, Theis Muncholm Thillemann, Søren Paaske Johnsen, Alma Becic Pedersen
Department of Orthopedic surgery , Horsens Regional Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital
Background: Mortality after hip fracture is two-fold higher in men compared with women. It is unknown whether sex-related differences in the quality of in-hospital care contribute to the higher mortality among men.
Purpose / Aim of Study: To examine sex-related differences in quality of in-hospital care, 30-day mortality, length of hospital stay and readmission among patients with hip fracture in a population-based cohort study.
Materials and Methods: Using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 25,354 patients ¡Ý65 years (29 % were men). Outcome measures included quality of in-hospital care as reflected by seven process performance measures, 30- day mortality, length of stay and readmission within 30 days after discharge. Data were analysed using multivariable regression techniques.
Findings / Results: In general, there were no substantial sex-related differences in quality of in- hospital care. The relative risk for receiving the individual process performance measure ranged from 0.91 (95 % CI 0.85-0.97) to 0.97 (95 % CI 0.94-0.99) for men compared to women. The 30-day mortality was 15.9 % for men and 9.3 % for women corresponding to an adjusted odds ratio of 2.30 (95 % CI 2.09-2.54). The overall readmission risk within 30 days after discharge was 21.6 % for men and 16.4 % for women (adjusted odds ratio of 1.38 (95 % CI 1.29-1.47)). No difference in length of stay was observed between men and women.
Conclusions: Sex-differences in the quality of in- hospital care appeared not to explain the higher mortality and risk of readmission among men hospitalized with hip fracture.
Department of Orthopedic surgery , Horsens Regional Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital ; Department of Orthopedic Surgery, Aarhus University Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital
Background: Mortality after hip fracture is two-fold higher in men compared with women. It is unknown whether sex-related differences in the quality of in-hospital care contribute to the higher mortality among men.
Purpose / Aim of Study: To examine sex-related differences in quality of in-hospital care, 30-day mortality, length of hospital stay and readmission among patients with hip fracture in a population-based cohort study.
Materials and Methods: Using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 25,354 patients ¡Ý65 years (29 % were men). Outcome measures included quality of in-hospital care as reflected by seven process performance measures, 30- day mortality, length of stay and readmission within 30 days after discharge. Data were analysed using multivariable regression techniques.
Findings / Results: In general, there were no substantial sex-related differences in quality of in- hospital care. The relative risk for receiving the individual process performance measure ranged from 0.91 (95 % CI 0.85-0.97) to 0.97 (95 % CI 0.94-0.99) for men compared to women. The 30-day mortality was 15.9 % for men and 9.3 % for women corresponding to an adjusted odds ratio of 2.30 (95 % CI 2.09-2.54). The overall readmission risk within 30 days after discharge was 21.6 % for men and 16.4 % for women (adjusted odds ratio of 1.38 (95 % CI 1.29-1.47)). No difference in length of stay was observed between men and women.
Conclusions: Sex-differences in the quality of in- hospital care appeared not to explain the higher mortality and risk of readmission among men hospitalized with hip fracture.
Thomas Colding-Rasmussen, Peter Horstmann, Hanna Dahlgren, Eva Lidén, Werner Hettwer, Michael Mørk Petersen
Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; , BONESUPPORT AB, Lund, Sweden; , BONESUPPORT AB, Lund, Sweden; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark
Background: Antibiotic containing materials are often used for dead space management after surgical treatment of bone infections.
Purpose / Aim of Study: To measure early in-vivo plasma concentrations of Vancomycin and Gentamicin eluted from locally implanted antibiotic-eluting bone graft substitutes (BGS), and to evaluate possible in-vitro elution interactions of combined use.
Materials and Methods: In-vivo plasma concentrations were measured in 5 patients (M/F: 3/2, mean age 67 (52-81) years), who underwent local implantation (range: 10-20 mL) with either a Vancomycin- (n=1), a Gentamicin-eluting BGS (n=3) or a combination of both (n=1). Plasma was collected 1 and 3 hours after implantation and once daily during the first three postoperative days. In-vitro elution profiles of Vancomycin- and Gentamicin-eluting BGS (5 mL each) were compared in 4 different scenarios: Each product individually, both products side-by-side, and mixed together. The ratio between product and medium was kept the same in all tests. Samples (20% of the medium to mimic conditions in a contained bone defect) were collected and replaced on day 1-8, 21, and 28 for analysis.
Findings / Results: Mean blood plasma concentration of Vancomycin was 0.3 mg/L (Range: 0.0- 1.6mg/L) and 0.5 mg/L (Range: 0.0- 2.1mg/L) for Gentamicin. In-vitro release curves of Vancomycin and Gentamicin showed a similar appearance for the 4 different scenarios. Both the in-vivo and in-vitro curves displayed an initial peak, a gradual drop, and sustained lower concentrations during the study period.
Conclusions: Local in-vivo implantation of Vancomycin- and Gentamicin-eluting bone graft substitutes, results in safe low plasma concentrations in the first three days after surgery when used individually or in combination. Further, when tested in-vitro, combined use did not seem to influence their eluting abilities.
Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; , BONESUPPORT AB, Lund, Sweden; , BONESUPPORT AB, Lund, Sweden; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark ; Department of Orthopedics, Musculoskeletal Tumor Section, Rigshospitalet, University of Copenhagen, Denmark
Background: Antibiotic containing materials are often used for dead space management after surgical treatment of bone infections.
Purpose / Aim of Study: To measure early in-vivo plasma concentrations of Vancomycin and Gentamicin eluted from locally implanted antibiotic-eluting bone graft substitutes (BGS), and to evaluate possible in-vitro elution interactions of combined use.
Materials and Methods: In-vivo plasma concentrations were measured in 5 patients (M/F: 3/2, mean age 67 (52-81) years), who underwent local implantation (range: 10-20 mL) with either a Vancomycin- (n=1), a Gentamicin-eluting BGS (n=3) or a combination of both (n=1). Plasma was collected 1 and 3 hours after implantation and once daily during the first three postoperative days. In-vitro elution profiles of Vancomycin- and Gentamicin-eluting BGS (5 mL each) were compared in 4 different scenarios: Each product individually, both products side-by-side, and mixed together. The ratio between product and medium was kept the same in all tests. Samples (20% of the medium to mimic conditions in a contained bone defect) were collected and replaced on day 1-8, 21, and 28 for analysis.
Findings / Results: Mean blood plasma concentration of Vancomycin was 0.3 mg/L (Range: 0.0- 1.6mg/L) and 0.5 mg/L (Range: 0.0- 2.1mg/L) for Gentamicin. In-vitro release curves of Vancomycin and Gentamicin showed a similar appearance for the 4 different scenarios. Both the in-vivo and in-vitro curves displayed an initial peak, a gradual drop, and sustained lower concentrations during the study period.
Conclusions: Local in-vivo implantation of Vancomycin- and Gentamicin-eluting bone graft substitutes, results in safe low plasma concentrations in the first three days after surgery when used individually or in combination. Further, when tested in-vitro, combined use did not seem to influence their eluting abilities.
Julie Ladeby Erichsen, Peter Andersen, Carsten Jensen, Frank Damborg, Bjarke Viberg, Lonnie Froberg
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: Distal Intra-Articular Tibia Fractures (DIATF) is challenging to treat and severe loss of physical function affecting working abilities has been reported.
Purpose / Aim of Study: To investigate differences in physical function and complications following DIATF surgery with two-stage Open Reduction Internal Fixation (ORIF) or External Fixation (EF).
Materials and Methods: A search was conducted using PUBMED, Embase, Cochrane Central, Open Grey, Orthopaedic Proceedings and WHO International Clinical Trials Registry Platform. Studies with level of evidence I-IV comparing EF with two-stage ORIF of DIATF in patients (>18 years) were included for review. 3071 studies were identified and screened by two independent authors according to the PRISMA guidelines. Cochrane Risk of bias Tool for RCT and non-randomised studies (ROBIN-1) were used to assess risk of bias.
Findings / Results: One RCT study and four cohort studies with 254 patients, 150 two-stage ORIF and 104 EF, was included. The median follow-up ranged from 12-38 months. The RCT had low risk of bias while the cohort studies had moderate risk. All studies reported decreased physical function. A comparison of results was difficult because a variety of function scores were used. EF had a higher superficial infection frequency due to pinn infection (28% EF vs 9% two-stage ORIF) and a tendency towards higher mal- and non-union frequency (14% EF vs 7% two- stage ORIF; 6% EF vs 3% two-stage ORIF).
Conclusions: Current evidence for physical function and complications following DIATF surgery with either two-stage ORIF or EF is of low quality. However, all present studies report decreased physical function following DIATF operated on with either two-stage ORIF or EF. Number of complications was generally low. A well-designed study with a large sample size is needed.
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: Distal Intra-Articular Tibia Fractures (DIATF) is challenging to treat and severe loss of physical function affecting working abilities has been reported.
Purpose / Aim of Study: To investigate differences in physical function and complications following DIATF surgery with two-stage Open Reduction Internal Fixation (ORIF) or External Fixation (EF).
Materials and Methods: A search was conducted using PUBMED, Embase, Cochrane Central, Open Grey, Orthopaedic Proceedings and WHO International Clinical Trials Registry Platform. Studies with level of evidence I-IV comparing EF with two-stage ORIF of DIATF in patients (>18 years) were included for review. 3071 studies were identified and screened by two independent authors according to the PRISMA guidelines. Cochrane Risk of bias Tool for RCT and non-randomised studies (ROBIN-1) were used to assess risk of bias.
Findings / Results: One RCT study and four cohort studies with 254 patients, 150 two-stage ORIF and 104 EF, was included. The median follow-up ranged from 12-38 months. The RCT had low risk of bias while the cohort studies had moderate risk. All studies reported decreased physical function. A comparison of results was difficult because a variety of function scores were used. EF had a higher superficial infection frequency due to pinn infection (28% EF vs 9% two-stage ORIF) and a tendency towards higher mal- and non-union frequency (14% EF vs 7% two- stage ORIF; 6% EF vs 3% two-stage ORIF).
Conclusions: Current evidence for physical function and complications following DIATF surgery with either two-stage ORIF or EF is of low quality. However, all present studies report decreased physical function following DIATF operated on with either two-stage ORIF or EF. Number of complications was generally low. A well-designed study with a large sample size is needed.
Christian Wied, Nicolai Bang Foss, Morten Tange Kristensen, Gitte Holm, Thomas Kallemose, Anders Troelsen
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: There is an increasing number of high-risk, elderly and severely comorbid patients, scheduled for dysvascular lower extremity amputations (LEA). An easy to apply risk stratification tool would be of great value for individualizing postoperative monitoring and care.
Purpose / Aim of Study: To assess whether the Surgical Apgar Score (SAS, 0-10 points) is a prognostic tool capable of identifying the most vulnerable patients with major complications (including death) following LEA surgery. The SAS score is based on intraoperative heart rate, blood pressure and blood loss.
Materials and Methods: An observational cohort study of 170 dysvascular patients undergoing transtibial (TTA, n=70) or transfemoral (TFA, n=100) amputations from 2013- 2015. Data on perioperative morbidity and mortality was collected retrospectively.
Findings / Results: When the calculated scores were divided into four groups (SAS: 0-4, 5-6, 7-8, 9-10) a logistic regression model showed a significant linear association between decreasing SAS and postoperative complications (all patients: OR = 2.00 [1.33-3.03], p = 0.001). This effect was pronounced for TFA (OR = 2.61 [1.52-4.47], p < 0.001). The AUC from the models were estimated to (all patients = 0.648 [0.562-0.733], p = 0.001), (TFA = 0.710 [0.606- 0.813], p<0.001), and (TTA = 0.528 [0.383-0.672], p = 0.472) pointing at a moderate discriminatory power of the SAS in predicting postoperative complications in TFA patients.
Conclusions: It seems warranted that the SAS provides the medical staff with information regarding the potential development of complications following TFA. The scoring system could prove useful in guiding preventive strategies such as optimizing intraoperative blood pressure or heart rate. The SAS showed no discriminatory power in the TTA sub- group, most likely due to an overall better condition of the patients.
Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre; Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical Therapy, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
Background: There is an increasing number of high-risk, elderly and severely comorbid patients, scheduled for dysvascular lower extremity amputations (LEA). An easy to apply risk stratification tool would be of great value for individualizing postoperative monitoring and care.
Purpose / Aim of Study: To assess whether the Surgical Apgar Score (SAS, 0-10 points) is a prognostic tool capable of identifying the most vulnerable patients with major complications (including death) following LEA surgery. The SAS score is based on intraoperative heart rate, blood pressure and blood loss.
Materials and Methods: An observational cohort study of 170 dysvascular patients undergoing transtibial (TTA, n=70) or transfemoral (TFA, n=100) amputations from 2013- 2015. Data on perioperative morbidity and mortality was collected retrospectively.
Findings / Results: When the calculated scores were divided into four groups (SAS: 0-4, 5-6, 7-8, 9-10) a logistic regression model showed a significant linear association between decreasing SAS and postoperative complications (all patients: OR = 2.00 [1.33-3.03], p = 0.001). This effect was pronounced for TFA (OR = 2.61 [1.52-4.47], p < 0.001). The AUC from the models were estimated to (all patients = 0.648 [0.562-0.733], p = 0.001), (TFA = 0.710 [0.606- 0.813], p<0.001), and (TTA = 0.528 [0.383-0.672], p = 0.472) pointing at a moderate discriminatory power of the SAS in predicting postoperative complications in TFA patients.
Conclusions: It seems warranted that the SAS provides the medical staff with information regarding the potential development of complications following TFA. The scoring system could prove useful in guiding preventive strategies such as optimizing intraoperative blood pressure or heart rate. The SAS showed no discriminatory power in the TTA sub- group, most likely due to an overall better condition of the patients.
Hagen Schmal, Anke Bernstein, Elia Roul Langenmair, Eva Johanna Kubosch
Department of Orthopaedics and Traumatology, Odense University Hospital; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany
Background: Intraarticular infections can rapidly lead to osteoarthritic degradation, but the association of inflammation and cartilage destruction is not yet fully understood.
Purpose / Aim of Study: Aim of this clinical trial was to correlate inflammation severity with parameters of cartilage metabolism.
Materials and Methods: Patients with acute septic arthritis were enrolled in a clinical trial and the effusions (n=76) analyzed. Cytokines and cell function were also investigated using a human in-vitro model of joint infection.
Findings / Results: Higher synovial IL-1â levels were associated with a higher degree of disease severity. Additionally, IL-1â concentrations correlated with infectious serum markers, but not with age or co-morbidity. Both higher serum leucocytes and synovial IL-1â were associated with increased intraarticular collagen type II cleavage products (C2C) indicating cartilage degradation. Joints with pre-infectious lesions had higher C2C levels and were more susceptible to inflammation. Infections led to increased concentrations of typical cartilage metabolites as bFGF, BMP-2, and BMP-7. A subgroup analysis revealed increased synovial IL-1â levels in patients with an arthroplasty, which could be confirmed utilizing the in-vitro model. In contrast to IL-4 and IL-10, FasL levels increased steadily in-vitro, reaching higher levels without chondrocytes (CHDR). Likewise, the viability of synovial fibroblasts (SFB) during infection was higher in the presence of CHDR and associated with increased TGFâ levels.
Conclusions: C2C reliably mark cartilage destruction during septic arthritis, which is associated with up-regulation of typical cartilage turnover cytokines. Chondrocytes exhibit an anti- inflammatory effect, which is associated with an increased resistance of SFB to infections and FAS-mediated cytotoxicity.
Department of Orthopaedics and Traumatology, Odense University Hospital; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University Medical Center Freiburg, Germany
Background: Intraarticular infections can rapidly lead to osteoarthritic degradation, but the association of inflammation and cartilage destruction is not yet fully understood.
Purpose / Aim of Study: Aim of this clinical trial was to correlate inflammation severity with parameters of cartilage metabolism.
Materials and Methods: Patients with acute septic arthritis were enrolled in a clinical trial and the effusions (n=76) analyzed. Cytokines and cell function were also investigated using a human in-vitro model of joint infection.
Findings / Results: Higher synovial IL-1â levels were associated with a higher degree of disease severity. Additionally, IL-1â concentrations correlated with infectious serum markers, but not with age or co-morbidity. Both higher serum leucocytes and synovial IL-1â were associated with increased intraarticular collagen type II cleavage products (C2C) indicating cartilage degradation. Joints with pre-infectious lesions had higher C2C levels and were more susceptible to inflammation. Infections led to increased concentrations of typical cartilage metabolites as bFGF, BMP-2, and BMP-7. A subgroup analysis revealed increased synovial IL-1â levels in patients with an arthroplasty, which could be confirmed utilizing the in-vitro model. In contrast to IL-4 and IL-10, FasL levels increased steadily in-vitro, reaching higher levels without chondrocytes (CHDR). Likewise, the viability of synovial fibroblasts (SFB) during infection was higher in the presence of CHDR and associated with increased TGFâ levels.
Conclusions: C2C reliably mark cartilage destruction during septic arthritis, which is associated with up-regulation of typical cartilage turnover cytokines. Chondrocytes exhibit an anti- inflammatory effect, which is associated with an increased resistance of SFB to infections and FAS-mediated cytotoxicity.