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.