Session 12: Trauma II

Eske Brand, Peter Toquer, Thomas Bloch, Kristoffer Hare
Orthopedic department, Slagelse Hospital; Orthopedic department, Slagelse Hospital; Orthopedic department, Slagelse Hospital; Orthopedic department, Slagelse Hospital


Background: Little to no evidence exist regarding the postoperative regime after osteosynthesis of proximal tibial fractures (PTF). Even so, current literature suggests no weightbearing (NWB) for approx. 6-21 weeks following osteosynthesis of a tibia plateau fracture until sign of healing. However, few studies suggest that early weightbearing as tolerated (WBT) may be allowed without the risk of secondary fracture displacement.
Purpose / Aim of Study: To investigate if immediate WBT after osteosynthesis of a proximal tibial fracture causes secondary fracture displacement. Furthermore, to describe functional outcome, adverse events and return to work and normal activity in these patients.
Materials and Methods: The study is an ongoing prospective cohort study including all patients surgically treated for a proximal tibia fracture at Slagelse Hospital from March 2018 to March 2020. Patients are followed up in the outpatient clinic at 2, 6 and 12 weeks and 1 year. Fracture displacement is classified as displacement more than 2 mm on radiography validated by the authors.
Findings / Results: So far 50 patients was treated for a proximal tibia fracture. 8 patients were excluded. 34 of 42 were allowed immediate WBT (most noticable 11 type AO 41B3, 8 type 41C3), 8 were instructed in NWB (all type 41C3). Patients were followed from 2 weeks to 1 year. Secondary fracture displacement was seen in 2 of 34 in WBT group (one type 41C3 and one 41B3) and 1 of 8 in the NBW group. Maximum displacement was 3mm. Functional test was the 30 second chair- stand-test. At 2, 6, 12 weeks and 1 year the WBT group performed (median) 8 (0;19, n=32), 13,5 (0;24, n=29), 15 (0;28, n=30) and 17 (0;30, n=8) respectively compared to the NWT group which performed 0 (0, n=8), 3,5 (0;13, n=8), 9,5 (0;24, n=8) and 10 (5;15, n=3). There were 6 adverse events in the WBT group and 3 in the NWB group. At 2 weeks, 9 of 31 in the WBT group and 0 of 8 in the NWB had returned to normal function. At 12 weeks 14 of 30 in the WBT group and 5 of 8 in the NWB group had returned to normal function.
Conclusions: We found immediate WBT to be a viable postoperative regime after a surgically treated proximal tibial fracture with secondary fracture displacement in 2 of 34 of patients allowed immediate WBT.

Jonas Kristensen, Inger Mechlenburg, Birn Ida
Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital


Background: Stroke can have severe consequences such as depression, pain, impaired functional capacity, decreased quality of life and death. Furthermore, stroke has been associated with an increased risk of falls and fractures in the elderly population. Up to 75% of all patients with stroke fall within six months after their stroke and studies suggest that 1- 15% experience a fall-related fracture. There are no recent national studies in Denmark on the incidence of fractures after the first episode of stroke in the elderly Danish population.
Purpose / Aim of Study: To estimate the incidence of fall-related fractures in patients aged 65 and older with first episode of stroke, and to estimate the incidence of specific fracture types for this group of patients. Another objective was to investigate stroke severity and marital status, as risk factors for fractures.
Materials and Methods: A large retrospective data-set of 116,519 patients with first episode of stroke was extracted from the Danish Stroke Registry between January 2003 and December 2017. The occurrence of fall-related fractures was then identified in the Danish National Patient Registry for this group of patients. A univariate analysis was conducted and a multivariate analysis was conducted to determine the relationship between stroke severity and fractures, and marital status and fractures, adjusting for multiple confounders. In the multivariate analysis, Cox regression with time varying covariates was used, taking time dependent variables into account.
Findings / Results: The incidence rate of fall-related fractures post- stroke was 41.07 per 1000 person-years between 2003-2017 in Denmark. A total of 15,872 (14.86%) sustained a fracture and the mean time at risk until outcome was 3.67 years post-stroke. Factors associated with an increased risk of fractures were a mild, moderate, severe and unknown stroke severity, living alone, age, female sex and high alcohol intake.
Conclusions: The incidence rate of fall-related fractures in Denmark was 41.07 per 1000 person-years. Femur fracture was the most common fracture type. Moreover, mild, moderate and severe stroke severity and living alone at the time of stroke were found to be risk factors for fracture.

Mads Terndrup, Ilija Ban, Søren Kring, Morten Thomsen, Anders Troelsen, Peter Tengberg
Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital


Background: The posterolateral approach to the distal tibia is reported to be safe, allowing anatomical reduction of posterior malleolar (PM) fractures
Purpose / Aim of Study: To examine the rate of major complications following posterior fragment fixation through the posterolateral approach, in a prospective cohort
Materials and Methods: The study was registered on clinicaltrials.gov (NCT03107767). Adult patients with trimalleolar fractures, were included prospectively. The PM fractures were treated with fixation of the PM through a posterolateral approach, from June 2016 to June 2018, as dictated by a standardized algorithm in a single level III trauma center serving 540.000 people. Radiological and clinical follow- up was performed in a dedicated ankle fracture out-patient clinic as part of the “PRO-Malleolus Algorithm study”. Follow-up was set at 6, 12 and 52 weeks each including weightbearing radiographs
Findings / Results: 90 patients with mean age of 53y ([range 18y-86y]) were included. 96% were evaluated with a pre-operative computed tomography scan. 67 patients (74,4%) had AO/OTA fracture type 44B3, and twelve (24,4%) 44C-type fractures. One patient had an isolated PM fracture. 80% of patients were allowed full weight bearing in a circular cast from day one. 18 patients (20%) suffered major complications. There were six cases of failure (FAIL) requiring reoperation, either due to loss of reduction and/or suboptimal surgical reduction, two cases of deep infections (D.INF) requiring intravenous antibiotics and/or surgical debridement. Four patients suffered persisting pain (PP+REOP), requiring reoperation, including arthroscopy, arthrodesis or other reconstructive surgery (NB* not including implant removal procedures > 9 months post- ORIF). Six patients with severe persisting pain required long term follow up at a foot/ankle or pain center (PP- REOP). Additionally, ten patients had minor complications, six of which were superficial wound problems
Conclusions: Although ORIF through a posterolateral approach is an important tool in managing these injuries, the major complication rate remains 20% in our prospective study. This is considerably higher than other retrospective series, claiming that major complication and reoperation rates are minimal

Pia Kjær Kristensen, Anne Mette Falstie-Jensen, Søren Paaske Johnsen
Department of Orthopaedic Surgery, Horsens Regional Hospital ; Department of Clinical Epidemiology, Aarhus University Hospital; Danish Center for Clinical Health Services Research, Aalborg University


Background: Health care systems have implemented continuous monitoring to improve quality of care. However, it is unknown whether the results are improving equally for all patients.
Purpose / Aim of Study: We aimed to identify patient characteristics associated with the chance of receiving the best quality of care and temporal trends in patient-related disparities in the quality of acute hip fracture care.
Materials and Methods: A Danish population-based cohort study among patients treated with hip fracture from 2007 through 2016 (N=56,376). A logistic model was used to identify patient-related characteristics that predicted the chance of receiving all recommended process performance measures in accordance with national clinical guideline for hip fracture care. Based on this model we identified the worst off patients (i.e., the 10% of the population with the lowest chance) and best off patients (i.e., the 10% of the patients with the highest chance). The patient-related characteristics included age, gender, fracture severity, comorbidity, immigration status, frailty, family income, level of education, labour market attachment, cohabitant status, and geographical residence. We examined the proportion of best off and worst off patients that received all recommended care according to calendar year and calculating absolute difference in percentage points.
Findings / Results: Throughout the 10-year period best off patients were more likely to be females, between 75 and 84 years, and living alone, whereas worst off patients were more likely to be males, aged 85 years or above, living together with a partner, to have high comorbidity, and a subtrochanteric fracture. The proportion of best off and worst off patients, which received high quality of care, increased throughout the period. However, the largest increase was seen among best off patients, thus the absolute difference increased from 12 percentage points in 2007 to 25 percentage points in 2016.
Conclusions: Throughout the 10-year period, quality of care increased for both best off and worst off patients treated for acute hip fracture. However, inequality increased concurrently as a larger increase in receiving the best quality of care were seen among best off patients than worst off patients.

Damgren Vesterager Jeppe, Kjær Kristensen Pia , Petersen Irene , Becic Pedersen Alma
Department of Clinical Epidemiology, Aarhus University Hospital; Department of Clinical Medicine, Regional hospital Horsens; Institute of Epidemiology & Health, University College London; Department of Clinical Epidemiology, Aarhus University Hospital


Background: Post-surgery infections after hip fracture is one of the most serious and challenging complications - adversely affecting mortality, quality of life, and hospital costs. Hospital variation in 30 days mortality after hip fracture has not entirely been explained by patient characteristics, treatment or hospital level factors. We therefore, hypotheses that there is variation in post-surgery infections after hip fracture, which potentially could explain variation in mortality.
Purpose / Aim of Study: The aim of this study was to examine the variation in the incidence rates (IR) of post- surgery infections after hip fracture at hospital- and regional level in Denmark.
Materials and Methods: In this nationwide population-based cohort study we included all patients who underwent surgery for an incident hip fracture in the time period from 2012 to 2017 (n=31.304) using the Danish Multidisciplinary Hip Fracture Registry. Patients were followed 30 days from surgery date. Post-surgery infection was defined as any hospital- treated infection registered during hospital admission or outpatient clinic visit at a public or private hospital. Data on infections were collected from the Danish National Patient Register using International Classification of diseases codes. The IRs were calculated per 1000 person-days for hospitals (n=25) and regions (n=5).
Findings / Results: Overall the IR of post-surgery infection was 5.98 (95% confidence interval (CI), 5.82 – 6.16) per 1000 person-days. The IR for hospitals varied from 2.82 (95% CI, 1.86 - 4.28) per 1000 person-days to 16.44 (95% CI, 15.20 – 17.78) per 1000 person-days. The IR for regions varied from 4.88 (95% CI, 4.58 – 5.19) per 1000 person-days to 7.13 (95% CI, 6.68 – 7.59) per 1000 person-days. The incidence rate- ratio between the highest and lowest IR was 5.82 (95% CI, 3.81 – 9.36) for hospitals, whereas it was 1.46 (95% CI, 1.33 -1.60) for regions.
Conclusions: This study showed a substantial variation in the incidence of post-surgery infections following hip fracture between Danish hospitals and regions.

Pernille Bovbjerg, Ditte Høgh, Lonnie Froberg, Hagen Schmal, Moustapha Kassem
Department of Orthopedic Surgery, Sygehus Sønderjyllaand; Department of Orthopedic Surgery, Sygehus Sønderjylland; Department of Orthopedic Surgery, Odense Universitity Hospital; Department of Orthopedic Surgery, Odense University Hospital; Department of Endocrinology, Odense University Hospital


Background: The aging of our society is associated with an increasing number of fragility or insufficiency fractures of the pelvis. However, the current standard of care with bedrest and pain control is still a matter of debate. The instability in these fracture patterns seems often to require surgical stabilization, but patients’ comorbidities significantly increase the risk of complications. Teriparatide (PTH) is a medical treatment option for osteoporosis and known to have a anabolic effect on bone.
Purpose / Aim of Study: Does treatment with PTH increase bone healing in insufficiency fractures of the pelvis compared to standard treatment?
Materials and Methods: To summarize the current status of PTH treatment for pelvic insufficiency fractures, we conducted a systematic review searching the databases PubMed, Embase and Cochrane. Patients who had sustained an insufficiency fracture of the pelvis was included. Intervention was medical treatment with PTH compared to standard treatment with bedrest af pain control. If a study included pathologic fractures or patients received PTH before the the time of the fracture it was excluded. Our primary outcome was fracture healing, secondary outcome measures comprised pain, mobility and patient reported outcome measures (PROM).
Findings / Results: After 299 articles were screened, 8 articles were included in the qualitative synthesis. However, only 3 studies were comparative including 1 randomized controlled trial. This was the only study scoring low using the Cochrane bias assessment tool. In total 131 patients were included, 59 patients received PTH and 74 patients did not. Besides one study age range from 73 to 84 years. All articles described a positive effect for PTH on fracture healing and pain. None reported on non-union, PROM or comparable mobility scoring. 2 studies were included in a meta-analysis: Fracture healing and reported pain were assessed after 8 weeks and were significantly improved in the group being treated with PTH (p<0.01).
Conclusions: The results of the systematic review indicate that there is a positive effect of PTH on healing and pain in patients with a insufficiency fracture of the pelvis, but further research is necessary.

Anne Marie Nyholm, Henrik Palm, Anders Troelsen, Kirill Gromov
Clinical Orthopaedic Research Hvidovre, Ortopædkirurgisk afdeling, Hvidovre Hospital; Ortopædkirurgisk afdeling, Bispebjerg Hospital; Clinical Orthopaedic Research Hvidovre, Ortopædkirurgisk afdeling, Hvidovre Hospital; Clinical Orthopaedic Research Hvidovre, Ortopædkirurgisk afdeling, Hvidovre Hospital


Background: Insufficient reduction of a displaced femoral neck fracture (dFNF) has previously been demonstrated as a main risk factor for reoperation within 12 months.
Purpose / Aim of Study: To evaluate potential risk factors for insufficient reduction of dFNF.
Materials and Methods: 654 dFNF treated parallel implants with available pre- and postoperative x-rays were collected from the Danish Fracture Database. Data included age, gender, educational level of the surgeon (attending surgeon present vs no attending surgeon present) and whether the fracture was reduced open or closed. The X-rays were evaluated for initial fracture displacement and quality of reduction in accordance with the Garden classification and posterior tilt (PT), as well as bone quality measured as the Cortical Thickness Index (CTI). The fracture was considered sufficiently reduces if there was a maximum of 2 mm step-off in calcar, no varus and <10° PT. From the Dansk Anæstesi Database (DAD) data on height, weight and type of anesthesia (regional vs general) was collected. 244 cases were excluded from analysis due to missing data from DAD. Logistical regression was used to investigate risk factors for insufficient reduction.
Findings / Results: 410 cases with complete dataset were included. 243 (60%) were women and mean age was 68.3 years. 49 (12%) were Garden II with >20° PT, 173 (42%) were Garden III and 188 (46%) were Garden IV type fracture. In only 140 (34%) cases was the fracture sufficiently reduced. In a univariate analysis of the included variables, no single variable demonstrated any significant association with risk of insufficient reduction. In a multivariable analysis increased initial fracture displacement (Garden IV vs Garden II type fracture OR 2.3; CI 1.12-4.54) and decreasing BMI (<20 vs >25 OR 1.96; CI 1.04-3.73) were associated with increased odds for insufficient reduction. No association was seen for age, gender, type of anesthesia, educational level of the surgeon, CTI or method of reduction.
Conclusions: In the current setup the main risk factor for insufficient reduction seems to be the initial fracture displacement, with risk increasing with the severity of the displacement. This should be considered when choosing internal fixation as treatment of a dFNF.

Hjalte Oltmann, Lonnie Froberg
Department of Orthopaedic Surgery, Odense University Hospital; Department of Orthopaedic Surgery, Odense University Hospital


Background: More than 90% of traumatic brain injuries (TBI) are classified as minor (mTBIs), defined by as GSC 14 or 15. Previously, cerebral CT- scans (CCT) have been considered the standard diagnostic, but the last decade CCT have become questionable since it is expensive and an increased risk of cancer has been proven. Serum 100 Beta Protein (S100B) is the most useful biomarker to select adult patients with low-risk mTBI for CT scans in the Emergency Department (ED).
Purpose / Aim of Study: 1.To compare the time spent in the ED for patients who are primarily evaluated with a CCT compared to those for whom their S100B level is used as a biomarker. 2.To investigate whether S100B as a tool for pre-CCT is cost-effective compared to CCT scan from a health care perspective.
Materials and Methods: Data from 94 patients presented to the ED at OUH between September 2018 and April 2019 were analyzed. Number of patients having a CCT (62), S100B (19), and S100B followed by a CCT (13) was registered. Patients were treated following national clinical guideline. The total time from primary examination by the ED doctor to final conclusion, based on S100B and/or CTC, was recorded. To summarize cost-effectiveness of S100B an Incremental Cost-Effectiveness Ratio (ICER) was calculated. A wilcoxon rank-sum test was used to calculate p-values.
Findings / Results: The patients who went directly to the CCT had a median total time spent in the ED of 109 minutes (CI: 96-123) compared to 124 minutes (CI: 107- 160, p=0.097) for patients who had S100B and 252 minutes (CI: 210-393, p=0.001) for those who first underwent an S100B and afterwards a CCT. The ICER of using S100B in the ED was in this study 11.1. For patients who only had S100B the ICER was -92.1 and for patients receiving both S100B and CCT the ICER was 2.4.
Conclusions: No statistically significant difference was found in time spent in the ED for patients having either a CCT or only a S100B. However, time spent was doubled when the patient needed a CCT following the S100B. The ICER of using the S100B analysis is -11.1 DKK saved for each additionel minute spent in the ED for patients who primarily had a S100B test. These findings suggest that S100B is a cost- effective analysis.

Christina Frandsen, Maiken Stillling , Glassou Eva Natalia , Hansen Torben Baek
Orthopedic department, University Clinic for Hand, Knee and Hip surgery, Regional hospital West Jutland; Ortopedic department, Aarhus University Hospital; Orthopedic department, University Clinic for Hand, Knee and Hip surgery, Regional hospital West Jutland; Orthopedic department, University Clinic for Hand, Knee and Hip surgery, Regional hospital West Jutland


Background: Best treatment practices for hip fracture patients have been thoroughly investigated, and most institutions have integrated an evidence-based treatment protocol. However, it seems, that common practice often defies evidence due to patient characteristics or departmental constraints.
Purpose / Aim of Study: to investigate the degree of adherence to our protocol for hip fractures based on seven indicators, with a goal of 80% adherence.
Materials and Methods: Prospective data on all patients with a hip fracture admitted to our institution from January 1 2011 to December 31 2017, were collected in the Holstebro Hip Fracture Database (HHFD) (n=3050). The following seven treatment indicators, mirroring the different procedural steps and diverse care groups were investigated: 1) Pre-operative regional block 2) Surgical delay 3) Peri-operative antibiotics 4) Osteosynthesis 5) Thromboprophylaxis 6) Postoperative mobilization 7) Blood transfusions Data was obtained from the HHFD and patient records. Descriptive statistics as proportions with 95% confidence intervals were used. Degree of adherence was clarified by an all-or-none test.
Findings / Results: Preliminary results for 500 consecutive patients showed indicator 2, 3, 4 and 6 met our 80% goal. However, the all-or-none test showed a mean fulfillment for all seven indicators for only 15.7%(12.8-19.3%) of patients. Corrected for contraindications the all-or-none test showed a mean 29.9%(25.3-35%) adherence.
Conclusions: In our small and dedicated hip fracture unit, with great focus on best-treatment practice, the 80% goal were only met in less than one third of patients. This may not necessarily reflect suboptimal treatment, as the major problem may be, that patient characteristics does not always allow for standardized treatment in this heterogeneous patient group. Further research on more individualized treatment protocols may be needed.

Nicholas Bonde, Peter Tengberg, Anders Troelsen, Mads Terndrup
Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital; Department of Orthopedics, Hvidovre Hospital


Background: External fixation (ExFix) of unstable ankle fractures prior to final open reduction and internal fixation (ORIF) is the treatment of choice, when primary ORIF is deemed unsafe, often due to severe swelling or soft tissue damage. Complications after final ORIF will also be examined
Purpose / Aim of Study: To determine the average time (in hours), from ExFix to final ORIF in staged procedures, and the rate of loss of reduction before final ORIF, requiring either adjustment or renewal of the ExFix in the operating room (OR)
Materials and Methods: Surgical records of adult patients undergoing ankle fracture ORIF at single Level III trauma center serving 540.000 people, from 1st of June 2011 to 1st of January 2018, were reviewed. ExFix procedures were identified and radiographs and patient records were analyzed individually by two of the authors, with a minimum 1,5 year follow up. Time of injury was defined as the time of primary radiograph and the timestamp of ExFix and final ORIF was extracted from surgical logs
Findings / Results: 1102 patients were reviewed. 45 were treated with initial ExFix as primary ORIF was deemed unsafe. 38 patients subsequently underwent final ORIF and 7 patients kept the ExFix as final treatment. Initial ExFix was performed within an average of 27,2 hours CI (15.8 - 38.6), from time of injury. The mean time to surgery was 10 days CI (7,5 – 12,5), resulting in a total average delay until final ORIF of 11 days CI (8,6 – 13,6). 19 patients (42%) had open fractures and 26 (58%) closed injuries, requiring ExFix due to swelling or soft tissue damage. After initial ExFix, four patients (11%) suffered loss of reduction before final ORIF, requiring adjustment or renewal of the ExFix in the OR. After final ORIF, complications were seen in 16 cases (35,6%), seven of which (18,4%) were failures of the final ORIF requiring reoperation
Conclusions: Staged procedures prolonged immobilization and hospitalization. In our cohort one in ten patients suffered loss of reduction before final ORIF. Failure and severe complication rates after final ORIF remained high, in this high risk group of patients. Minimally invasive, definitive salvage procedures could be considered as an alternative to initial ExFix, when primary ORIF is deemed unsafe