Umeå University's logo

Background: Over the past decades, spine research has grown substantially, and as the body of literature grows, it is valuable to understand the research landscape. This study aims to examine the geographic origins, author demographics, including the number and gender of authors, and publication output of three prominent spine journals and to assess their scholarly impact.

Methods: A retrospective, bibliometric, cross-sectional analysis was conducted on articles published between 2000 and 2004 (period 1, P1), 2010 and 2014 (period 2, P2), and 2020 and 2024 (period 3, P3) in three spine journals: European Spine Journal (ESJ), Spine, and The Spine Journal (TSJ). Bibliometric data were retrieved using PubMed's Application Programming Interface (API).

Results: Some 14,653 articles underwent analysis. Spine had the highest output in P2 (2946 articles), while TSJ peaked in P3. A marked increase in Asian contributions was observed, with a notable surge in Chinese publications within ESJ; these rose from 4 in P1 to 454 in P3. In the TSJ, the number of articles written by Asian authors increased from 23 to 306. Female first authorship in the ESJ increased from 10.0% to 17.1% and in TSJ, from 5.5% to 14.1%. A notable increase in the average number of authors per publication was observed across all journals. In ESJ, this rose from 4.3 to 7.6; in Spine, from 4.6 to 9.0; and in TSJ, from 4.0 to 8.3.

Conclusions: This study reveals a rise in the number of scientific publications in spine surgery, characterized by an increasing proportion of publications originating from Asia, a higher number of authors per publication, and a growing proportion of female authors. While the progress observed in contributing countries and the increase in gender diversity are promising, disparities persist.

Background: This study sought to characterize a cohort of talar neck and body fractures, focusing on fracture characteristics, associated injuries, treatment and outcome.

Methods: We reviewed adult patients registered in the Swedish Fracture Register 2011–2021 with talar neck and body fractures. A minimum 2-year follow-up was conducted for treatment outcomes.

Results: We included 313 patients (318 fractures, median age 34 years, 67 % men) of which 106 involved the neck, 134 the body and 78 combined body and neck. 36 % had associated injuries. Operative treatment was implemented for 55 neck (52 %), 81 body (60 %), and 70 combined fractures (90 %). Reoperation rates were, 35 % for neck, 32 % for body and 44 % for combined fractures.

Conclusion: Talar fractures primarily occur in men and are associated with other fractures. A majority of the fractures are treated operatively and one in three patients undergoes reoperation, with higher reoperation rates in combined body and neck fractures.

BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR).

METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality.

RESULTS: The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF.

CONCLUSION: Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.

Although femoral neck fractures (FNFs) are common injuries, optimal treatment methods have not yet been established. FNFs disproportionately affect the ageing population and are associated with high disability and mortality. Since Garden’s classification was introduced in 1961, hip arthroplasty has emerged as the preferred method for treating displaced FNFs in older patients. However, for undisplaced or minimally displaced FNFs, internal fixation has been the prevailing treatment option, regardless of biological age and activity. Reoperation rates after internal fixation have been reported, ranging from 8% to 19%. Reducing treatment failures and subsequent re-operations is of clinical significance to improve care for this vulnerable patient population. Several treatment options, such as internal fixation and arthroplasty, have been proposed to manage basicervical FNFs. However, the number of available reports on clinical outcomes is limited.

Paper 1 is a register-based observational cohort study of the panorama of FNFs in Sweden based on data from the Swedish Fracture Register (SFR), allowing us to include a large number of FNFs for analysis. Data on age, sex, seasonal variation, trauma mechanism and location, fracture type, treatment and mortality are presented.

Paper 2 is an observational cohort study based on data from the SFR. All basicervical FNFs between 2011 and 2020 and entered into SFR at the participating sites (Sunderbyn, Umeå, Östersund, Karlstad, Uppsala and Göteborg) were screened. A review of radiographs and medical records was performed. We found basicervical FNFs to be difficult to classify accurately. Furthermore, undisplaced basicervical FNFs have a low re-operation rate when treated with internal fixation compared to displaced basicervical FNFs.

Paper 3 is an observational cohort study based on data from three centres (Umeå, Skellefteå and Danderyd) with a consecutive series of undisplaced FNFs treated with internal fixation. This study investigated the association between dorsal and anterior tilt on the lateral radiograph and the outcome after internal fixation. We found that dorsal tilt >20° and anterior tilt >10° increased the risk of treatment failure.

Paper 4 is an observational cohort study based on data from the SFR. We identified a cohort of stress-induced FNFs and reviewed patient medical records to verify a correct diagnosis and identify treatment failures. The study sought to depict the panorama of stress-induced FNFs and document instances of treatment failures. We found low mortality rates, a biphasic age distribution and a large proportion of displaced FNFs.

Paper 5 is a case series of 93 occult FNFs treated with internal fixation. A consecutive series of occult FNFs from four centres were included (Umeå, Skellefteå, Danderyd, Malmö). The treatment failure rate after internal fixation was analysed, and it was shown that 6% led to treatment failure.

Aims: Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undis-placed femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Methods: We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately.

Results: Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group.

Conclusion: In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods.

BACKGROUND: Reports in the literature on talar head fractures are rare and limited to case reports and small case series.

QUESTIONS/PURPOSES: This study aimed to describe a national cohort of talar head fractures for fracture characteristics, associated injuries, treatment, and reoperations.

METHODS: We reviewed all radiographs of patients enrolled in the SFR between 2011 and 2021 showing talar head fractures (AO/OTA 81-A3). We excluded those with talar head avulsion fractures, misclassified, multiple registrations, or with a privacy notice in their medical records. The cohort was reviewed using medical records and radiographs at a minimum 2-year follow-up.

RESULTS: The study included 32 patients (33 fractures) ≥18 years of age. The median age was 32 (range 18-65) years, 84 % were men, and the main trauma mechanisms were motor vehicle accidents (28 %) and falls from heights (28 %) and graded as high-energy injuries in 50 % of the cases. 18 (55 %) were displaced and 15 (45 %) had comminuted fractures. 14 talar head fractures (42 %) had multiple injuries to the same foot. 21 patients (66 %) underwent surgical treatment, most commonly with screw fixation. Surgery was performed in 15 of 18 patients with displaced fractures. Four patients were reoperated, one with arthrodesis of the talonavicular joint and three for implant removal. No cases of avascular necrosis were identified.

CONCLUSIONS: Talar head fractures are rare and occur mainly in men. They are associated with other foot injuries. Most talar head fractures are treated operatively. In this case series, we did not identify any case of avascular necrosis.

LEVELS OF EVIDENCE: IV, retrospective observational cohort study.

BACKGROUND: Pathological fractures are challenging in orthopedic surgery and oncology, with implications for the patient's quality of life, mobility and mortality. The efficacy of oncological treatment on life expectancy for cancer patients has improved, but the metastatic pattern for bone metastases and survival is diverse for different tumor types. This study aimed to evaluate survival in relation to age, sex, primary tumor and site of the pathological fractures.

METHODS: All pathological fractures due to cancer between 1 September 2014 and 31 December 2021 were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, tumor type, fracture site and mortality were collected.

RESULTS: A total of 1453 patients with pathological fractures were included (48% women, median age 73, range 18-100 years). Unknown primary tumors were the most common primary site (n = 308). The lower extremities were the most common site of pathological fractures. Lung cancer had the shortest median survival of 78 days (range 54-102), and multiple myeloma had the longest median survival of 432 days (range 232-629). The site at the lower extremity had the shortest (187 days, range 162-212), and the spine had the longest survival (386 days, range 211-561). Age, sex, primary type and site of the pathological fractures were all associated with mortality.

INTERPRETATION: Age, sex, primary tumor type and site of pathological fractures were associated with survival. Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival.

BACKGROUND: Between 2 to 10% of non-displaced femoral neck fractures (nFNF) cannot be diagnosed on plain radiographs and require further imaging investigation to be detected or verified. These fractures are referred to as occult hip fractures. This study aimed to report treatment failures, reoperations and mortality in a consecutive series of occult femoral neck fractures (FNF) treated with internal fixation (IF).

METHODS: A retrospective multicenter study was performed based on a consecutive series of patients aged ≥ 60 years with an occult magnetic resonance imaging (MRI) verified Garden I and II FNF sustained after a trauma and treated with primary IF. We included 93 patients with a minimum 2-year follow-up. Radiographic assessment encompassed pre- and postoperative tilt, implant inclination, MRI and treatment failure. Data on reoperation and mortality were collected. Treatment failure was defined as fixation failure, nonunion, avascular necrosis or posttraumatic osteoarthritis.

RESULTS: The study comprised of 93 patients (72% women, 67/93) with a mean age of 82 (range, 60-97) years. Overall, 6 (6%) patients had major reoperations. 2 (2%) had minor reoperations. One-month mortality was 7%, 1-year mortality was 20% and 2-year mortality was 31%.

CONCLUSION: This multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. These fractures seem to have a lower complication rate compared to nFNF identified on plain radiographs.

LEVEL OF EVIDENCE: Prognostic Level V. See Instructions to Authors for a complete description of levels of evidence.

BACKGROUND: Epidemiological data on talus fractures from large nationwide and multicenter studies are rare. This study aims to describe the epidemiology, fracture classification and treatment regimens of talus fractures in a large adult Swedish population.

METHODS: This observational study is based on data from the Swedish Fracture Register (SFR) including talar fractures in patients ≥18 with a sustained fracture between 2012 and 2021. Epidemiological data on sex, age, injury date, injury mechanism and type (high or low energy trauma), fracture classification (side, type), initial treatment and mortality were analysed.

RESULTS: We included 1794 talus fractures (1757 patients, 60 % men). Mean age was 40.3 years (range 18-96), and a biphasic age distribution was seen in women. High-energy trauma caused 33 % of all talus fractures. Of all talus fractures, 817 (45.5 %) were classified as AO/OTA type A fractures (avulsion), 370 (20.6 %) as type B (neck) and 435 (24.2 %) as type C (body). The remaining 172 (9.6 %) talus fractures were not classified/unclassifiable. Men were in the majority in all fracture groups except A1. For type A1-3, B1 and C1-2 fractures, most patients were treated non-operatively; in B2-3 and C3 fractures most patients received operative management. Fracture fixation with screws was the dominating surgical treatment. The overall 30-day mortality was 0.2 %.

CONCLUSION: Talus fractures are most commonly encountered in young and middle-aged men. In contrast to men, a biphasic age distribution was observed in women. Approximately half of the talus fractures are avulsions. Operative treatment, mostly screw fixation, is performed in more complex fracture configurations (B2, B3 and C3 fractures).

LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

BACKGROUND AND PURPOSE: Stress fractures of the femoral neck (sFNFs) are uncommon injuries. Studies on sFNFs are rare. We describe the demographics, classification, treatment, reoperation rates, and mortality in a cohort of sFNF patients from the Swedish Fracture Register (SFR).

PATIENTS AND METHODS: We included 146 patients ≥ 18 years of age with an sFNF registered in the SFR between 2011 and 2020. The cohort was linked with the Swedish Arthroplasty Register and reviewed using medical records and radiographs. We assessed the presence of disorders of bone remodeling, duration of symptoms, fracture classification, treatment, reoperations, and mortality.

RESULTS: The mean age was 58 years (21-96), 75% were women and the median duration of symptoms was 23 days (1-266). 40% of patients had disorders of bone remodeling. 54% were undisplaced (uFNF), 30% displaced (dFNF), and 16% basicervical (bFNF). 14% of patients < 60 years were treated nonoperatively, by internal fixation (IF) in 77% and by arthroplasty in 10%. Patients ≥ 60 years were treated nonoperatively in 10%, IF in 40%, and arthroplasty in 49%. Nonoperative treatment was reserved for uFNFs or bFNFs, resulting in 35% receiving late surgery. The overall secondary or late surgery rate was 19%. Mortality was 2% at 90 days and increased to 3% at 1 year.

INTERPRETATION: sFNF has a biphasic age distribution. One-third of patients presented with a displaced FNF and those managed nonoperatively for an undisplaced sFNF were at risk of late surgery. The mortality rates for patients with these injuries was low.