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Mukka, Sebastian
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Publications (10 of 37) Show all publications
Sayed-Noor, A., Mukka, S., Mohaddes, M., Kärrholm, J. & Rolfson, O. (2019). Body mass index is associated with risk of reoperation and revision after primary total hip arthroplasty: a study of the Swedish Hip Arthroplasty Register including 83,146 patients. Acta Orthopaedica, 90(3), 220-225
Open this publication in new window or tab >>Body mass index is associated with risk of reoperation and revision after primary total hip arthroplasty: a study of the Swedish Hip Arthroplasty Register including 83,146 patients
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2019 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 90, no 3, p. 220-225Article in journal (Refereed) Published
Abstract [en]

Background and purpose: The prevalence of obesity is on the rise, becoming a worldwide epidemic. The main purpose of this register-based observational study was to investigate whether different BMI classes are associated with increased risk of reoperation within 2 years, risk of revision within 5 years, and the risk of dying within 90 days after primary total hip arthroplasty (THA). We hypothesized that increasing BMI would increase these risks.

Patients and methods: We analyzed a cohort of 83,146 patients who had undergone an elective THA for primary osteoarthritis between 2008 and 2015 from the Swedish Hip Arthroplasty Register (SHAR). BMI was classified according to the World Health Organization (WHO) into 6 classes: < 18.5 as underweight, 18.5-24.9 as normal weight, 25-29.9 as overweight, 30-34.9 as class I obesity, 35-39.9 as class II obesity, and ≥ 40 as class III obesity.

Results: Both unadjusted and adjusted parameter estimates showed increasing risk of reoperation at 2 years and revision at 5 years with each overweight and obesity class, mainly due to increased risk of infection. Uncemented and reversed hybrid fixations and surgical approaches other than the posterior were all associated with increased risk. Obesity class III (≥ 40), male sex, and increasing ASA class were associated with increased 90-day mortality.

Interpretation: Increasing BMI was associated with 2-year reoperation and 5-year revision risks after primary THA where obese patients have a higher risk than overweight or normal weight patients. As infection seems to be the main cause, customizing preoperative optimization and prophylactic measures for obese patients may help reduce risk.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2019
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-157811 (URN)10.1080/17453674.2019.1594015 (DOI)000464635000001 ()30931664 (PubMedID)
Available from: 2019-04-03 Created: 2019-04-03 Last updated: 2019-06-13Bibliographically approved
Mukka, S., Sjöholm, P., Chammout, G., Kelly-Pettersson, P., Sayed-Noor, A. & Sköldenberg, O. (2019). External Validity of the HOPE-Trial Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians. JBJS Open Access, 4(2), 1-7, Article ID e0061.
Open this publication in new window or tab >>External Validity of the HOPE-Trial Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians
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2019 (English)In: JBJS Open Access, ISSN 2472-7245, Vol. 4, no 2, p. 1-7, article id e0061Article in journal (Refereed) Published
Abstract [en]

Background: Randomized controlled trials (RCTs) are the most reliable way of evaluating the effect of new treatments by comparing them with previously accepted treatment regimens. The results obtained from an RCT are extrapolated from the study environment to the general health care system. The ability to do so is called external validity. We sought to evaluate the external validity of an RCT comparing the results of total hip arthroplasty with those of hemiarthroplasty for the treatment of displaced femoral neck fractures in patients ≥80 years of age.

Methods: This prospective, single-center cohort study included 183 patients ≥80 years of age who had a displaced femoral neck fracture. All patients were screened according to the inclusion and exclusion criteria for an RCT comparing total hip arthroplasty and hemiarthroplasty. The population for this study consisted of patients who gave their informed consent and were randomized into the RCT (consenting group, 120 patients) as well as those who declined to give their consent to participate (non-consenting group, 63 patients). The outcome measurements were mortality, complications, and patient-reported outcome measures. Follow-up was carried out postoperatively with use of a mailed survey that included patient-reported outcome questionnaires.

Results: We found a statistically significant and clinically relevant difference between the groups, with the non-consenting group having a higher risk of death compared with the consenting group. (hazard ratio, 4.6; 95% confidence interval, 1.9 to 11.1). No differences were found between the groups in terms of patient-reported outcome measures or surgical complications.

Conclusions: This cohort study indicates a higher mortality rate but comparable hip function and quality of life among eligible non-consenters as compared with eligible consenters when evaluating the external validity of an RCT in patients ≥80 years of age with femoral neck fracture.

Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Place, publisher, year, edition, pages
JBJS, 2019
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-161074 (URN)10.2106/JBJS.OA.18.00061 (DOI)
Available from: 2019-06-27 Created: 2019-06-27 Last updated: 2019-06-28Bibliographically approved
Chammout, G., Kelly-Pettersson, P., Hedbeck, C.-J., Stark, A., Mukka, S. & Sköldenberg, O. (2019). HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians: A Randomized Controlled Trial. JBJS Open Access, 4(2), Article ID e0059.
Open this publication in new window or tab >>HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians: A Randomized Controlled Trial
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2019 (English)In: JBJS Open Access, E-ISSN 2472-7245, Vol. 4, no 2, article id e0059Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background: The choice of primary hemiarthroplasty or total hip arthroplasty in patients ≥80 years of age with a displaced femoral neck fracture has not been adequately studied. As the number of healthy, elderly patients ≥80 years of ageis continually increasing, optimizing treatments for improving outcomes and reducing the need for secondary surgery is an important consideration. The aim of the present study was to compare the results of hemiarthroplasty with those of totalhip arthroplasty in patients ≥80 years of age.

Methods: This prospective, randomized, single-blinded trial included 120 patients with a mean age of 86 years (range, 80 to 94 years) who had sustained an acute displaced femoral neck fracture <36 hours previously. The patients were randomized to treatment with hemiarthroplasty (n = 60) or total hip arthroplasty (n = 60). The primary end points were hip function and health-related quality of life at 2 years. Secondary end points included hip-related complications and reoperations, mortality, pain in the involved hip, activities of daily living, surgical time, blood loss, and general complications.The patients were reviewed at 3 months and 1 and 2 years.

Results: We found no differences between the groups in terms of hip function, health-related quality of life, hip-related complications and reoperations, activities of daily living, or pain in the involved hip. Hip function, activities of daily living,and pain in the involved hip deteriorated in both groups compared with pre-fracture values. The ability to regain previous walking function was similar in both groups.

Conclusions: We found no difference in outcomes after treatment with either hemiarthroplasty or total hip arthroplasty inactive octogenarians and nonagenarians with a displaced femoral neck fracture up to 2 years after surgery. Hemiarthroplastyis a suitable procedure in the short term for this group of patients.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Place, publisher, year, edition, pages
Wolters Kluwer, 2019
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-158836 (URN)10.2106/JBJS.OA.18.00059 (DOI)
Available from: 2019-05-10 Created: 2019-05-10 Last updated: 2019-07-05
Mohammed, J., Mukka, S., Hedbeck, C.-J., Chammout, G., Gordon, M. & Sköldenberg, O. (2019). Reduced periprosthetic fracture rate when changing from a tapered polished stem to an anatomical stem for cemented hip arthroplasty: an observational prospective cohort study with a follow-up of 2 years. Acta Orthopaedica, 90, 1-10
Open this publication in new window or tab >>Reduced periprosthetic fracture rate when changing from a tapered polished stem to an anatomical stem for cemented hip arthroplasty: an observational prospective cohort study with a follow-up of 2 years
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2019 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 90, p. 1-10Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background and purpose - Straight collarless polished tapered stems have been linked to an increased risk for periprosthetic femur fractures in comparison with anatomically shaped stems, especially in elderly patients. Therefore, we evaluated the effect of an orthopedic department's full transition from the use of a cemented collarless, polished, tapered stem to a cemented anatomic stem on the cumulative incidence of postoperative periprosthetic fracture (PPF). Patients and methods - This prospective single-center cohort study comprises a consecutive series of 1,077 patients who underwent a cemented hip arthroplasty using either a collarless polished tapered stem (PTS group, n = 543) or an anatomic stem (AS group, n = 534). We assessed the incidence of PPF 2 years postoperatively and used a Cox regression model adjusted for age, sex, ASA class, cognitive impairment, BMI, diagnosis, and surgical approach for outcome analysis. Results - Mean age at primary surgery was 82 years (49-102), 73% of the patients were female, and 75% underwent surgery for a femoral neck fracture. The PPF rate was lowered from 3.3% (n = 18) in the PTS group to 0.4% (n = 2) in the AS group. The overall complication rate was also lowered from 8.8% in the PTS group to 4.5% in the AS group. In the regression model only cognitive dysfunction (HR 3.8, 95% CI 1.4-10) and the type of stem (PTS vs AS, HR 0.1, CI 0.0-0.5) were correlated with outcome. Interpretation - For elderly patients with poor bone quality use of cemented anatomic stems leads to a substantial reduction in periprosthetic fracture rate without increasing other complications.

National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-159714 (URN)10.1080/17453674.2019.1624339 (DOI)31154885 (PubMedID)
Available from: 2019-06-04 Created: 2019-06-04 Last updated: 2019-06-13
Farhang, M., Mukka, S., Bergström, U., Svensson, O. & Sayed-Noor, A. S. (2019). The trend of radiological severity of hip fractures over a 30 years period: a cohort study. BMC Musculoskeletal Disorders, 20(1), Article ID 358.
Open this publication in new window or tab >>The trend of radiological severity of hip fractures over a 30 years period: a cohort study
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2019 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 20, no 1, article id 358Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Despite advances in operative techniques and preoperative care, proximal femur fractures (PFF) still represent a great public health problem. Displacement and fracture stability have been assumed as important determinants of treatment modality and outcome in such fractures. Purpose of this study was to determine whether the radiological severity of PFF fractures has increased over time.

METHODS: In a cohort study, the plain radiographs of all patients with PFF aged over 50 years who were admitted to Umeå University Hospital in 1981/82, 2002 and 2012 were recruited to examine the types of fractures.

RESULTS: The ratio of undisplaced to displaced femoral neck (FN) fractures was 30 to 70% in 1981/82, 28 to 72% in 2002 and 25 to 75% in 2012. The ratio of stable to unstable intertrochanteric (IT) fractures was 64 to 36% in 1981/82, 68 to 32% in 2002 and 75 to 25% in 2012. The ratio of simple to comminute subtrochanteric fractures was 35 to 65% in 1981/82, 16 to 84% in 2002 and 12 to 88% in 2012. In both FN and IT fractures we found no statistical difference among these 3 study periods, p = 0.67 and p = 0.40. In subtrochanteric fractures we saw a tendency towards more comminute subtrochanteric fractures (1981/82 to 2012), p = 0.09.

CONCLUSIONS: We found no significant increment in the radiological severity of FN and IT over a 30 years' period. However, there was tendency towards an increase in comminute subtrochanteric fractures.

Keywords
Hip fracture, Proximal femoral fracture, Severity, Trend
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-162379 (URN)10.1186/s12891-019-2739-1 (DOI)31391031 (PubMedID)
Available from: 2019-08-19 Created: 2019-08-19 Last updated: 2019-08-19Bibliographically approved
Otten, V. T., Mukka, S., Nilsson, K. G., Crnalic, S. & Kärrholm, J. (2019). Uncemented cups with and without screw holes in primary THA: a Swedish Hip Arthroplasty Register study with 22,725 hips. Acta Orthopaedica, 90(3), 258-263
Open this publication in new window or tab >>Uncemented cups with and without screw holes in primary THA: a Swedish Hip Arthroplasty Register study with 22,725 hips
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2019 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 90, no 3, p. 258-263Article in journal (Refereed) Published
Abstract [en]

Background and purpose — Uncemented cups in total hip arthroplasty (THA) are often augmented with additional screws to enhance their primary stability. We investigated whether there is a difference in the risk for revision between cups with screw holes and cups without screw holes.

Patients and methods — We analyzed the risk for cup revision of uncemented cups registered in the Swedish Hip Arthroplasty Register (SHAR) between 2000 and 2017 with respe ct to the presence of screw holes. Only patients with primary osteoarthritis (OA) were included. 22,725 cups, including 12,354 without screw holes and 10,371 with screw holes, were evaluated. Revision rates at 2 and 10 years after the primary operation were analyzed.

Results — At a median follow-up time of 3.4 years (0–18), 459 cup revisions were reported. The main reasons for cup revision during the whole observation time were infection, 52% of all cup revisions, and dislocation, 26% of all cup revisions. The survival rate with cup revision due to aseptic loosening as endpoint was 99.9% (95% CI 99.8–99.9) at 2 years for both cups with and cups without screw holes, and the survival rates at 10 years were 99.5% (CI 99.3–99.7) and 99.1% (CI 98.6–99.5), respectively. Cups without screw holes showed a decreased risk of revision due to any reason at both 2 years (adjusted hazard ratio [HR] 0.6, CI 0.5–0.8) and 10 years (HR 0.7, CI 0.5–0.9).

Interpretation — We found a very low revision rate for aseptic loosening with modern, uncemented cup designs. Cups with screw holes had an increased risk of revision due to any reason in patients with primary OA

Place, publisher, year, edition, pages
Taylor & Francis Group, 2019
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-158054 (URN)10.1080/17453674.2019.1599777 (DOI)000469038600013 ()30955399 (PubMedID)
Available from: 2019-04-12 Created: 2019-04-12 Last updated: 2019-06-17Bibliographically approved
Hashem, A., Al-Azzawi, A., Riyadh, H., Mukka, S. & Sayed-Noor, A. (2018). Cementless, modular, distally fixed stem in hip revision arthroplasty: a single-center study of 132 consecutive hips. European Journal of Orthopaedic Surgery & Traumatology, 28(1), 45-50
Open this publication in new window or tab >>Cementless, modular, distally fixed stem in hip revision arthroplasty: a single-center study of 132 consecutive hips
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2018 (English)In: European Journal of Orthopaedic Surgery & Traumatology, ISSN 1633-8065, E-ISSN 1432-1068, Vol. 28, no 1, p. 45-50Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The use of cementless, modular, distally fixed stem in hip revision arthroplasty has increased during the last decades. We aimed to analyze the early and late postoperative complications, re-operation rate, and survival rate of the MP stem operated at our county hospital with relatively limited caseload.

METHODS: In this retrospective study, we included 132 hips operated with MP stem between January 2007-2014. An independent observer reviewed patients' medical records in July 2015 (18-102 months postoperatively, median 52.5) to collect the following data: age, sex, American Society of Anesthesiologists (ASA) class, body mass index, indication of revision, type of operation, early and late complications, re-operation rate, and mortality during study period.

RESULTS: The commonest indication for MP stem operation was aseptic loosening (72%). We found early and late postoperative complications in 29% of cases. The most common complication was prosthetic dislocation (8%), followed by intra-operative peri-prosthetic fracture (5%). The commonest indication for MP re-operation was soft tissue revision for infection (7%) followed by closed reduction for prosthetic dislocation (6%). We found no correlation between the age, sex, ASA class, and type of operation and the re-operation risk. Only one prosthesis was extracted giving a survival rate for 99% for the study period.

CONCLUSION: This study showed good results of the MP prosthesis with reasonable complication and re-operation rates and negligible extraction rate, indicating the good performance of this implant even when used in the setting of a county hospital with limited caseload.

Place, publisher, year, edition, pages
New York: Springer, 2018
Keywords
Hip revision, Cementless stem, Distally fixed, Outcome, Complication, Survival
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-138183 (URN)10.1007/s00590-017-2013-x (DOI)28702784 (PubMedID)
Available from: 2017-08-15 Created: 2017-08-15 Last updated: 2019-01-15Bibliographically approved
Mukka, S., Sjöholm, P., Perisynakis, N., Wahlström, P., Rahme, H. & Kadum, B. (2018). Radial head arthroplasty for radial head fractures: a clinical and radiological comparison of monopolar and bipolar radial head arthroplasty at a mean follow-up of 6 years. European Journal of Trauma and Emergency Surgery
Open this publication in new window or tab >>Radial head arthroplasty for radial head fractures: a clinical and radiological comparison of monopolar and bipolar radial head arthroplasty at a mean follow-up of 6 years
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2018 (English)In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941Article in journal (Refereed) Epub ahead of print
Abstract [en]

PURPOSE: The purpose of this study was to compare clinical and radiographic outcomes of bipolar and monopolar radial head arthroplasty in treatment of radial head fracture at a mean follow-up of 6 years.

METHODS: A retrospective multicentre cohort study of 30 patients treated for unreconstructable radial head fractures. Patients were treated either with a cemented bipolar or an uncemented monopolar radial head arthroplasty. All patients included were evaluated with patient-rated outcome questionnaire, physical examination, and radiographic evaluation at a mean of 6 years (range, 2-12 years) postoperatively.

RESULTS: There was no statistical difference in QuickDASH between the bipolar or monopolar groups. The majority of patients had no to little pain during rest. Neither flexion nor extension of the injured arm was significantly affected by the type of prosthesis. None of the patients in the bipolar group had any secondary surgery at the time of follow-up. In the monopolar group, four patients required removal of the arthroplasty. Signs of ulnohumeral degenerative changes were seen in the majority of patients in both groups (55% in the monopolar group, 92% in the bipolar group).

CONCLUSION: In this retrospective cohort study comparing a bipolar and a monopolar radial head arthroplasty for treatment of radial head fractures, we found comparable functional outcome but more revision procedures in the monopolar group at a mean follow-up of 6 years.

Place, publisher, year, edition, pages
Springer, 2018
Keywords
Elbow fracture, Elbow surgery, Mason classification, Radial head arthroplasty, Radial head fracture, Radial head prosthesis, Terrible triad
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-153240 (URN)10.1007/s00068-018-1042-4 (DOI)30382314 (PubMedID)
Available from: 2018-11-12 Created: 2018-11-12 Last updated: 2019-05-17
Knutsson, B., Mukka, S., Wahlström, J., Järvholm, B. & Sayed-Noor, A. S. (2018). The association between tobacco smoking and surgical intervention for lumbar spinal stenosis: cohort study of 331,941 workers. The spine journal, 18(8), 1313-1317
Open this publication in new window or tab >>The association between tobacco smoking and surgical intervention for lumbar spinal stenosis: cohort study of 331,941 workers
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2018 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 18, no 8, p. 1313-1317Article in journal (Refereed) Published
Abstract [en]

BACKGROUND CONTEXT: Tobacco smoking is an injurious habit associated with a number of chronic disorders. Its influence on disc metabolism and degeneration including lumbar spinal stenosis (LSS) has been investigated in the literature.

PURPOSE: We aimed to investigate whether tobacco smoking is an independent risk factor for undergoing surgical intervention for LSS.

STUDY DESIGN/SETTING: This is a prospective cohort study.

PATIENT SAMPLE: The patient sample of 331,941 workers was derived from a Swedish nationwide occupational surveillance program for construction workers.

OUTCOME MEASURE: The outcome measure included the incidence of undergoing surgical intervention for LSS in tobacco smokers versus no smokers.

MATERIALS AND METHODS: At inclusion, age, sex, body mass index (BMI), workers' job title, and self-reported smoking habits were registered. The workers were divided into four categories: never smoked, former smoker, moderate current (1-14 cigarettes/day), and heavy current (≥15 cigarettes/day). Patients who underwent a surgically treated LSS were defined using the relevant International Classification of Diseases (ICD) disease code derived from the Swedish National Patient Register.

RESULTS: A total of 331,941 participants were included in the analysis. Forty-four percent of the participants were non-smokers, 16% were former smokers, 26% were moderate smokers, and 14% were heavy smokers. The vast majority of construction workers were males (95%). During the average follow-up of 30.7 years, 1,623 participants were surgically treated for LSS. The incidence rate ratio (IRRs) of LSS varied across smoking categories, with the highest values found in heavy smokers. Compared with non-smokers, all smoking categories show an increased incidence of surgically treated LSS. The findings were consistent even when the comparison was performed for participants with BMIs between 18.5 and 25 and for participants aged between 40 and 74 years.

CONCLUSIONS: Tobacco smoking is associated with an increased incidence of surgically treated LSS. The effect seems to be dose related, whereby heavy smokers have a higher risk than moderate or former smokers.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Incidence, Lumbar, Risk factor, Spinal stenosis, Surgery, Tobacco smoking
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-145217 (URN)10.1016/j.spinee.2017.11.018 (DOI)000443585000002 ()29246850 (PubMedID)
Available from: 2018-02-23 Created: 2018-02-23 Last updated: 2018-10-01Bibliographically approved
Mellner, C., Eisler, T., Knutsson, B. & Mukka, S. (2017). Early periprosthetic joint infection and debridement, antibiotics and implant retention in arthroplasty for femoral neck fracture. HIP International, 27(4), 349-353
Open this publication in new window or tab >>Early periprosthetic joint infection and debridement, antibiotics and implant retention in arthroplasty for femoral neck fracture
2017 (English)In: HIP International, ISSN 1120-7000, E-ISSN 1724-6067, Vol. 27, no 4, p. 349-353Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Periprosthetic joint infection (PJI) is a severe complication of hip arthroplasty for femoral neck fractures (FNF). Debridement, antibiotics and implant retention (DAIR) is recommended in early PJI in association with stable implants. Few studies have evaluated the outcome of DAIR in this fragile population.The purpose of this study was to analyse risk factors for PJI and the short-term outcome of DAIR in FNF patients treated with a hip arthroplasty.

METHODS: A consecutive series of 736 patients (median age 81 years, 490 women, 246 men) had been treated with either a total hip arthroplasty or a hemi hip arthroplasty for a displaced FNF at our institution. 33 (4.5%) of the hips developed an early (&lt;6 weeks post operatively) PJI and 28 (3.8%) of these patients were treated according to the DAIR-protocol. Regression analyses were performed to assess risk factors for developing a PJI.

RESULTS: DAIR eradicated the PJI in 82% (23/28) of patients at a median follow-up of 31 (SD 29.8) months of the infected hips.The logistic regression analysis indicated that 2 or more changes of the primary dressing due to wound bleeding was associated with an increased risk for developing PJI (OR 4.9, 95% 1.5 to 16.1, p = 0.01).

CONCLUSIONS: The short-term success-rate of DAIR was unexpectedly favourable in this fragile patient population; the results being on par with that after PJI in osteoarthritis patients. The need for repeated bandage changes postoperatively indicates an increased risk for PJI and should prompt early surgical intervention.

Keywords
Antibiotics and implant retention (DAIR), Debridement, Femoral neck fracture, Hip Arthroplasty, Periprosthetic joint infection (PJI)
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-131599 (URN)10.5301/hipint.5000467 (DOI)000406433200006 ()28165600 (PubMedID)
Available from: 2017-02-17 Created: 2017-02-17 Last updated: 2018-06-09Bibliographically approved
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