Session 10: Trauma I

Torsdag d. 25. oktober
13:00-14:30
Lokale: Helsinki/Oslo
Chairmen: Peter Tengberg og Michael Brix

69. Is tranexamic acid for hip fracture patients safe? A consecutive cohort study based on complete follow-up in national databases
Bjarke Viberg, Per Hviid Gundtoft, Jesper Schønnemann, Lasse Pedersen, Lis Røhl Andersen, Kjell Titlestad, Carsten Fladmose Madsen, Jens Lauritsen, Søren Overgaard
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Hospital of Southern Jutland; Department of Orthopaedic Surgery and Traumatology, Hospital of South West Jutland; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Clinical Immunology, Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital


Background: Tranexamic acid (TXA) is an antifibrinolytic that may be used perioperatively to reduce the need of blood transfusions. Randomized controlled trials have demonstrated a transfusion reduction for hip fracture patients, but one study showed increased mortality and therefore questioning the safety of TXA in this patient group.
Purpose / Aim of Study: To estimate the association of introducing TXA perioperatively in hip fracture patients >65 years old on transfusion, haemoglobin, and mortality.
Materials and Methods: On October the 1st 2016 TXA was introduced in all hospitals in the Region of Southern Denmark and supposedly given during surgery for hip fracture patients. Data for two one year periods before (control group) and after (TXA group) the introduction were extracted from the Danish Interdisciplinary Registry for Hip Fractures and merged with blood transfusion and medication data from two regional databases. Cox proportional hazards were used to estimate and compare relative mortality at 30 and 90 days between the TXA and control group.
Findings / Results: No major baseline differences were identified for: age, sex, BMI, CCI, type of fracture, time to surgery or medication. Overall blood transfusions decreased from 31% to 27% (p<0.023) and the haemoglobin reduction on the first postoperative day was mean (95% CI) 1.10 (1.06; 1.14) with TXA and 1.17 (1.13; 1.22) without TXA (p<0.011). The 30-day mortality rate (95% CI) was 10% (9;12) for the TXA group compared to 10% (8;11) in the control group yielding an adjusted relative mortality risk of 1.07 (0.84;1.32). The 90-day mortality rate showed similar results.
Conclusions: Perioperative TXA for hip fracture patients was associated with lower transfusion frequency without change in mortality. Individual exposure assessment will be performed to confirm the results but perioperatively TXA seems safe.

70. Dynaloc vs. cancellous screws for treatment of femoral neck fractures. A randomized, prospective study
Lars Borris, Rikke Thorninger, Ole Brink
Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Aarhus University Hospital; Dept. of Orthopaedics, Aarhus University Hospital


Background: Failure of fracture fixation of femoral neck fractures (FNFs) is common after osteosynthesis with screws or dynamic hip screw (DHS) ranging from 5 % to 30 % in previous studies causing a lot of secondary interventions.
Purpose / Aim of Study: There is a need for more reliable systems to fix these fractures especially in patients below 70 years of age. Dynaloc® is a new implant consisting of 3 cancellous screws locked in a small side plate that has shown a good fracture retainment in biomechanical studies compared with 3 screws alone.
Materials and Methods: Primary endpoint was leg length discrepancy (LLD) after 3 months. Secondary endpoints were the generic health status and functional outcome measured by SF 12, WOMAC, EQ-5D and Harris hip score after 12 months. In addition we registered all adverse events, deaths and reoperations together with the healing properties in the 24 months study period. The study was stopped after inclusion of 40 patients (22 in the Dynaloc® - and 18 in the screw group) due to an high rate of hardware complains in the Dynaloc® group.
Findings / Results: The mean age was 71.9 (11.8) years with 60 % women. Fracture types were all Garden types with an overweight of displaced fractures (Garden III and IV) in the screw group. The duration of operation was significantly longer in the Dynaloc® vs the scew group. No statistically significant differences in terms of the primary or the secondary end-points were seen between the groups. A total 17 patients experienced at least one reoperation, 8 in the Dynaloc® - and 9 in the screw group. Four patients in the Dynaloc® group developed avascular necrosis of the femoral head late in the study period.
Conclusions: The new Dynaloc® implant did not result in any statistically, significant advantages in this study except for a tendency of a better facture retainment compared with screws.

71. THE INFLUENCE OF IBUPROFEN ON CLINICAL AND FUNCTIONAL OUTCOME AFTER COLLES' FRACTURE: PAIN, WRIST FUNCTION, AND RADIOLOGICAL MIGRATION
Marius Aliuskevicius, Svend Erik Østgaard, Sten Rasmussen
Orthopaedic Surgery, Aalborg University Hospital; Orthopaedic Surgery, Aalborg University Hospital; Orthopaedic Surgery, Aalborg University Hospital


Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) may delay bone healing. This knowledge is mostly based on retrospective studies or animal experiments.
Purpose / Aim of Study: The study purpose was to investigate whether Ibuprofen influences pain, functional and radiological outcomes after a Colles' fracture.
Materials and Methods: A total of 95 patients with Colles' fractures, treated by external fixation, were included at Aalborg University Hospital. The patients were randomized into three groups; Ibuprofen for 7 days; Ibuprofen for 3 days followed by a 4 days placebo; placebo for 7 days. The patient's 14 days experience of pain and demand of Tramadol were measured. The functional outcomes were the percentage differences in the motion between the injured and non- injured wrist, and the DASH score at 3 and 12 months. The radiological outcomes were changes in radius tilt, length, and inclination observed during and 6 weeks after the surgery.
Findings / Results: There was no significant difference in the pain score between the treatment groups, P=0.13. The use of Tramadol was lower in the Ibuprofen groups than in the placebo group, P=0.035. Ibuprofen treatment did not influence the range of motion, 0.148≤P≤0.963, and the DASH score, P=0.47. Patients in all groups demonstrated wrist motion improvement, close to 90% of normal amplitude. No clinically-relevant or statistically significant difference was observed in the radiological migration between the treatment groups, 0.064≤P≤0.81. The complication rate was higher in the 7-day Ibuprofen group compared to the placebo group, P=0.043.
Conclusions: Ibuprofen treatment demonstrated a Tramadol-sparing effect during the postoperative period and influenced neither wrist function, nor radiological migration. The complication rate was higher in the Ibuprofen-treated group than in the placebo-treated group.

72. Risk and prognosis of acute kidney injury in bisphosphonate users undergoing hip fracture surgery
Christian F. Christiansen, Nisha Shetty, Uffe Heide-Jørgensen, Henrik T. Sørensen, Vera Ehrenstein, Alma B. Pedersen
Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Epidemiology, Aarhus University Hospital


Background: Bisphosphonates may be nephrotoxic, but no study has examined risk or prognosis of laboratory confirmed acute kidney injury (AKI) in bisphosphonate users sustaining hip fracture.
Purpose / Aim of Study: To examine the risk and prognosis of AKI in bisphosphonate users undergoing hip fracture surgery.
Materials and Methods: This cohort study included older patients (≥ 65 years) with hip fracture surgery during 2005-2016 in the Central Denmark Region. By individual-level linkage of registries, we obtained information on hip fracture surgery, filled prescriptions, laboratory data, and comorbidities. Patients were categorized as current users (prescription filled 0 level linkage of registries, we obtained information on hip fracture surgery, filled prescriptions, laboratory data, and comorbidities. Patients were categorized as current users (prescription filled 0-90 days before surgery), former users (91-365 days), and non-users (no prescription within 365 days). Adjusted relative risks (aRRs) for AKI, and hazard ratios (aHRs) for mortality within 6-30 days (short-term) and 31-365 days (long-term) following AKI were computed with propensity term) following AKI were computed with propensity-score weighting.
Findings / Results: Among the 21,515 included patients, 1,641 (7.6%) were current and 542 (2.5%) were former users of bisphosphonates. The 5-day risk of AKI was 12% in current and former users and 15% in non-users. Compared with non-users, the aRR was 1.0 [95% confidence interval (CI): 0.9-1.1] in current and 1.0 (95% CI: 0.8-1.3) in former users. Among patients with AKI, short-term mortality was 13% in current, 15% in former, and 16% in non-users. The aHR aHR was 0.9 (95% CI: 0.6-1.4) in current compared with non-users. The long-term mortality was 22% in current, 24% in former, and 26% in non-users. The aHR was 0.7 (95% CI: 0.5-1.1) in current compared with non-users.
Conclusions: Bisphosphonate use was not associated with an increased risk of post-fracture AKI or post-AKI mortality up to one year of hip fracture surgery compared to non-users.

73. Reoperation after long and short intra medullary nail in patients with per- and subtrochanteric fracture. A multicentre cohort study.
Lasse Eriksen, Frederik Højsager, Katia Damsgaard Bomholt, Søren Overgaard, Jens Lauritsen, Bjarke Viberg, Henrik Palm
1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, ; 1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, ; 1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, ; 1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, ; 1. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, ; 2. Department of Orthopaedic Surgery and Traumatology, Kolding Hospital – part of Hospital Lillebaelt, and Department of Regional Health Research, University of Southern Denmark, ; 3. Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre,


Background: Short and long intramedullary nails (IMN) are frequently used in the management of femoral pertrochanteric (PTF) and subtrochanteric (STF) fractures but the literature is scarce on the optimal choice regarding reoperations.
Purpose / Aim of Study: To compare reoperation proportions between short and long IMN in patients with PTF and STF above 65 years.
Materials and Methods: From the Danish Interdisciplinary Registry for Hip Fractures patients from 2008-2013 were included with the procedure codes KNFJ51-52. Data was retrieved on age, sex, Charlson Comorbidity Index (CCI), and reoperations within 2 years. Included Patients accounted for approximately 45% of the Danish population. All health records were reviewed in the 12 hospitals for type of IMN and reason for reoperation. Odds ratio (OR) was calculated and adjusted for age, sex, and CCI. Results are listed with 95% confidence intervals.
Findings / Results: There were in total 3,281 patients but 127 were excluded due no knowledge of IMN type. The median age was 84.7 years and 73.1% were females. There were 2,313 PTF, 1,867 treated with short IMN and 378 with long IMN. There were 4.8% reoperations in short IMN and 7.1% in long IMN yielding an adjusted OR of 1.61 (1.02;2.52) in favour of short IMN. There were slightly more periimplant fractures and osteosynthesis failure in the long IMN group. There were 968 STF fractures, 308 treated with short IMN and 801 treated with long IMN. There were 10.7% reoperations for short IMN and 5.5% for long IMN yielding an OR of 0.46 (0.28;0.77) in favour of long IMN. There were substantially more periimplant fractures and osteosynthesis failure in the short IMN group.
Conclusions: This is the largest study to date showing that pertrochanteric fractures treated with short IMN and subtrochanteric fractures treated with long IMN were associated with fewer reoperations.

74. Surgery delay and risk of infections in hip fracture patients. A Danish nationwide cohort study, 2005-2016
Eva Natalia Glassou, Kaja Kjørholt, Torben Bæk Hansen, Alma Becic Pedersen
University clinic for hand, hip and knee surgery, Hospitalsenheden Vest; Department of Clinical Epidemiology, Aarhus University Hospital; University clinic for hand, hip and knee surgery, Hospitalsenheden Vest; Department of Clinical Epidemiology, Aarhus University Hospital


Background: Timing of surgery is of importance in patients with hip fractures. Surgery delay allows time for a beneficial stabilization of the patient's medical condition, but a delay may also increase the risk of complications.
Purpose / Aim of Study: To examine the association between surgery delay and infections in hip fracture patients with and without comorbidities.
Materials and Methods: All hip fracture patients aged >65 years registered in the Danish Multidisciplinary Hip Fracture Database (DMHFD) during 2005-2016 were included (n=72,520). Surgery delay was defined as time in hours (h) from hospital admission to surgery and divided into 4 groups (6, 12, 24 and 48). We calculated adjusted hazard ratios (HR) for infection 0-30 days and 31-90 days of surgery with 95% confidence interval (ci). As a measure of comorbidity, we used Charlson Comorbidity Index (CCI): low, medium and high.
Findings / Results: Surgery delay did not affect the risk of infection within 30 days of surgery either overall or in any CCI group. At 31-90 days of surgery, patients with a surgery delay of more than 6, 24 and 48 h had an increased risk of infection compared to their counterpart (6 h; HR 1.21 (ci 1.06 – 1.39), 24 h; HR 1.16 (ci 1.08 – 1.24), HR 48 h; 1.37 (ci 1.22 – 1.54). Further, we found that a surgery delay of 6 h or more was associated with increased risk of infections in patients with a low CCI, while the risk in patients with a medium or high CCI was affected first after 24 h and 48 h, respectively.
Conclusions: Surgery delay was associated with an increased risk of infection 31-90 days after surgery. However, surgery delay was most harmful in patients with a low comorbidity burden. This group of likely healthy patients might not be as healthy as we expect and thus, surgery should not be delayed in this group of patients.

75. Use of bisphosphonates before and after hip fracture surgery: A Danish population-based prevalence study, 2005-2015
Pia Kjær Kristensen, Nisha Shetty, Vera Ehrenstein, Alma Becic Pedersen
Ortopædkirurgisk afdeling , Regionshospitalet Horsens; Klinisk Epidemiologisk afdeling , Århus Universitetshospital ; Klinisk Epidemiologisk afdeling , Århus Universitetshospital ; Klinisk Epidemiologisk afdeling , Århus Universitetshospital


Background: Despite availability of effective pharmacotherapy, international research suggests that less than one-third of hip fracture patients receive treatment for secondary fracture prevention.
Purpose / Aim of Study: Cross-sectional analyses of bisphosphonate use before and after hip fracture surgery over several calendar periods.
Materials and Methods: We included patients aged 65+ with an incident hip fracture in 2005-2015 registered in Danish health registries, who were alive one year after surgery. Bisphosphonates use was defined as >=1 bisphosphonate prescription in the year before or after hip fracture. Incident users were previously treatment-naïve patients with >=1 bisphosphonate prescriptions in the year after hip fracture. We calculated the proportion of bisphosphonate users before and after hip fracture. We stratified according to sex and age groups.
Findings / Results: Among the 46,513 hip fracture patients surviving 1 year (1-year mortality = 29%), the proportion of bisphosphonate use before hip fracture varied between 8% and 12%, increasing slightly from 2005 to 2015. After hip fracture, the proportion of any bisphosphonate use within one year decreased from 17% in 2005 to 14% in 2011, whereupon it increased to 22% in 2015. The proportion of incident bisphosphonate use decreased from 4% in 2005 to 2% in 2010, whereupon it increased to 4% in 2015. A slightly lower proportion (range: 1-4%), but same pattern was seen for incident use before restricting to survivors. Stratified analysis according to sex and age groups will be presented at the conference.
Conclusions: Less than one-third had bisphosphonate after hip fracture. We observed only a slight increase in bisphosphonate user following hip fracture over the study period.

76. Risk of reoperation and mortality in undisplaced (internal fixation) versus displaced (arthroplasty) femoral neck fractures. A population-based study from Danish National Registries
Bjarke Viberg, Trine Frøslev, Søren Overgaard, Alma Becic Pedersen
Department of Orthopaedic Surgery and Traumatology, and Department of Regional Health Research, Kolding Hospital - part of Hospital Lillebaelt, and University of Southern Denmark; Department of Clinical Epidemiology, Aarhus University Hospital; Department of Orthopaedic Surgery and Traumatology, and Department of Clinical Research, Odense University Hospital and University of Southern Denmarki; Department of Clinical Epidemiology, Aarhus University Hospital


Background: The treatment of choice for patients with an undisplaced femoral neck fracture (FNF) is internal fixation (IF). However, there is a 10% risk of reoperation and if a FNF patient with a hip arthroplasty (HA) has lower reoperation and mortality proportion, it might be a better choice.
Purpose / Aim of Study: To compare risk of reoperation and mortality after treatment of undisplaced and displaced FNF with IF and HA, respectively, in patients’ ≥70 years old.
Materials and Methods: Data was retrieved from the Danish Interdisciplinary Registry for Hip Fractures during 2005-2015 and patients were followed up for minimum 1 year. Medication data was retrieved from the National Prescription Database. Reoperation (not amotio) and mortality risk in IF (undisplaced) and HA (displaced) patients were compared by calculating hazard ratios (HR) with 95 % confidence intervals (CI) (adjusted for age, sex, and Charlson Comorbidity Index).
Findings / Results: There were 10,337 FNF treated with IF and 19,260 with HA. There were no major baseline differences in sex, CCI, or medication. The cumulative incidence for reoperations after 5 years was 12.6% for IF and 10.7% for HA patients. The HR for reoperation was 1.22 (CI: 1.12; 1.32) for <1 year, 1.65 (CI: 1.34; 2.02) for year 1-2, and 0.82 (CI: 0.67; 1.00) for year 3-5 for IF vs. HA patients. The 1-year mortality was 27.3% for IF and 25.2% for HA patients. The HR for mortality was 0.82 (CI: 0.76; 0.89) after 0-30 days, 1.15 (CI: 1.09; 1.22) after 31-365 days, and 1.07 (CI: 1.03; 1.12) after 1-5 years. Reoperation was associated with mortality in all 5 years.
Conclusions: IF has a higher risk of reoperation within the first two years and higher overall mortality compared to HA and may therefore be a viable solution for undisplaced FNF. However, a better prediction of reoperation for IF in undisplaced FNF is warranted.

77. Validity and inter-tester reliability of ultrasound in diagnostics of extremity fractures in adults
Kaj Døssing, Ulla Nielsen, Helle Østergaard Helle Østergaard, Lars Bolvig Hansen, Kjeld Søballe, Inger Mechlenburg Inger Mechlenburg, Kaj Kaj Døssing
Orthopaedic Department, Viborg Regional Hospital; Department of Radiology, Viborg Regional Hospital; Orthopaedic Department, Viborg Regional Hospital; Ceclus Aarhus University Hospital, Aarhus University Hospital; Orthopaedic Department, Aarhus University Hospital; Orthopaedic Department, Aarhus University Hospital; ,


Background: The conventional diagnostic approach on suspicion of upper and lower extremity fracture consists of a clinical and a radiographic examination. Ultrasound has previously been shown to have a high diagnostic accuracy in diagnosing extremity fractures. However, ultrasound is known to be rater-dependent and hence it is relevant to investigate the inter-tester reliability in a clinical setting.
Purpose / Aim of Study: To investigate the validity and inter-tester reliability of ultrasound in diagnostics of extremity fractures in adults.
Materials and Methods: Eighty-seven adults referred to radiographic examination on suspicion of extremity fracture were consecutively enrolled in the study. Radiographs were used as the reference standard. All patients images were assessed for the presence or absence of a fracture by a senior consultant orthopedic surgeon and a radiographer (<1 year working experience) who were blinded to each other’s ultrasound results. To ensure blinding, the two raters scanned independently of each other in two different examination rooms and without informing the patients about the results. Sensitivity, specificity and Kappa values were calculated
Findings / Results: Prevalence of fractures was 22%. Sensitivity and specificity were found to be 0.92 (CI: 74;1.0) and 0.95 (0.86;0.98) respectively. The percent agreement among the raters were 89%, equal to a kappa value of 0.71.
Conclusions: Ultrasound screening on suspicion of extremity fracture has a high validity. The inter-tester reliability of ultrasound in diagnostics of extremity fractures in adults was found to be substantial.

78. Tourniquet use in lower limb fracture surgery - a systematic review and meta-analysis
Martin Præstegaard, Elin Beisvåg, Julie Ladeby Erichsen, Michael Brix, Bjarke Viberg
Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital; Department of Orthopaedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt


Background: Tourniquets are commonly used in today’s orthopaedic surgical practice and is known to have directly related complications. However, little evidence is available regarding the links between the use of a tourniquet and the amount of post- operative pain and other complications.
Purpose / Aim of Study: To conduct a systematic review and meta-analysis comparing tourniquet versus non-tourniquet use during fracture surgery of the lower limb in adult patients.
Materials and Methods: The study was registered in Prospero and a search was performed using the keyword “tourniquet” in Embase and as a MeSH-term in PubMed with no limitations (including language) applied. Available studies were screened using the Covidence software and demographic as well as outcome data was extracted from the final studies. Critical appraisal was performed according to Cochrane Risk of Bias guidelines. Pooled data was assessed for heterogeneity using Chi-squared and I2 tests, and results are shown with 95% confidence intervals.
Findings / Results: 7,473 studies were screened and 5 studies were included, 2 RCT and 3 cohort studies, but only 4 could be included in the meta-analysis. 24 hour postoperative pain demonstrated a mean difference of 0.8 (0.38;1.23) and the risk ratio for complications was 1.49 (0.8;2.77) yielding no difference for use of tourniquet or not. Length of in-hospital stay was longer in the tourniquet groups and an overall high risk of bias was found in the included studies.
Conclusions: Although the validity and statistical strength of our results are not strong enough to suggest a change of practice in tourniquet use, the operating surgeon should still carefully consider his or her decision to use a tourniquet in lower limb fracture surgery, as there are specific complications associated with tourniquet use and no current evidence to support its continued use.