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Bisphosphonates (BPs) are commonly used drugs in clinical practice. In this pilot study, we investigated whether bisphosphonate-related atypical femoral fractures (AFF) and osteonecrosis of the jaw (ONJ) occurred simultaneously in the same group of patients. Six ONJ patients were examined by an orthopedic surgeon and 5 AFF patients were examined by a dentist to look for manifestations of simultaneous occurrence of AFF in ONJ patients and vice versa. The required radiological investigations and previous medical and dental records were available. No simultaneous occurrence of AFF and ONJ was found in the examined patients. In this pilot study with limited sample size, no manifestations of simultaneous occurrence of AFF and ONJ were found. This could be an indication that these complications have different pathophysiologies and affect different subgroups of patients on long-term BP treatment.

Background: In situ fusion as salvage operation after calcaneal fractures has been used. In this retrospective investigation, a group of in situ fused patients is analyzed with long-term follow-up.

Methods: Twenty-nine patients with in situ single or multiple fusions performed between 1970 and 1990 were included. In 1998 these patients were examined with plain radiographs and computerized tomography (CT) scan of the affected foot. Also, a visual analogue score (VAS) for calcaneal fractures, short form health survey (SF-36), Olerud Molander score and American Orthopaedic Foot and Ankle society (AOFAS) hindfoot score were evaluated.

Results: The plain radiographs and CT scan showed severe remaining deformities in these patients. The outcome parameters were generally poor and correlated to the degree of remaining deformity.

Conclusions: Simple in situ fusion, without consideration of the deformity at hand, after a calcaneal fracture is not an adequate treatment and generally associated with poor outcome. (C) 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Introduction: Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open reduction and internal fixation or stem revision. This study aims to compare outcomes between uncemented and cemented stem revisions in managing Vancouver B2 and B3 fractures, considering factors such as hip-related complications, reoperations, and clinical outcome.

Methods: A retrospective cohort study was conducted at Danderyd Hospital, Sweden, from 2008 to 2022, encompassing operatively treated Vancouver B2 and B3 fractures. Patients were categorized into uncemented and cemented stem revision groups, with data collected on complications, revision surgeries, fracture healing times, and clinical outcomes.

Results: A total of 241 patients were identified. Significant differences were observed between the two groups in patient demographics, with the cemented group comprising older patients and more females. Follow up ranged from 1 to 15 years. Average follow up time was 3.9 years for the cemented group and 5.5 years for the uncemented group. The cemented stems demonstrated lower rates of dislocation (8.9% versus 22.5%, P = 0.004) and stem loosening (0.6% versus 9.3%, P = 0.004) than the uncemented method. Moreover, the cemented group exhibited shorter fracture healing times (11.4 weeks versus 16.7 weeks, P = 0.034). There was no difference in clinical outcome between groups. Mortality was higher in the cemented group.

Conclusions: This retrospective study indicates that cemented stem revision for Vancouver B2–3 fractures is correlated with lower dislocation and stem loosening rates, necessitating fewer reoperations and shorter fracture healing times compared with the uncemented approach. The cemented group had a notably higher mortality rate, urging caution in its clinical interpretation. Level of evidence III

PURPOSE: Periacetabular bone loss poses a considerable challenge in the longevity and stability of acetabular implants used in total hip arthroplasty (THA). Innovations in implant design, specifically the introduction of three-dimensional (3D) porous titanium constructs, might reduce bone resorption. The purpose of this study was to build upon our previous randomized controlled trial, which found no change in periacetabular bone loss between a 3D porous none-hydroxyapatite coated titanium cup and a standard porous hydroxyapatite coated cup over a two year follow-up period by extending the follow-up duration to ten years post-surgery.

METHODS: This was a single-centre, long-term follow-up study conducted over a ten year period in patients who had previously participated in a randomized controlled trial comparing a 3D porous titanium construct shell (PTC group) with a standard porous hydroxyapatite coated titanium shell (PC-group). The primary outcome measured was the change in bone mineral density (BMD) within four specific periacetabular zones, alongside overall bone loss, which was assessed through BMD in the lumbar spine at two, six and ten years postoperatively. Secondary outcomes included clinical outcome measures.

RESULTS: In total, 18 in the PTC and 20 in the PC group were analysed for the primary endpoint up to ten years. The mean bone mineral density in zones 1-4 was 3.7% higher in the PTC group than in the PC group at six years postoperatively and 12.0% higher at ten years. Clinical outcomes, and the frequency of adverse events did not differ between the groups.

CONCLUSIONS: The PTC group displayed superior long-term bone preservation compared to the PC group while maintaining similar clinical outcomes up to ten years postoperatively. Although with a small sample size, our findings suggest that porous titanium cups have the potential to minimize BMD loss around the cup which could contribute to improving THA outcomes and implant durability.

Introduction: Periprosthetic joint infection (PJI) is a devastating complication in hip arthroplasty surgery. Debridement, antibiotics (AB) and implant retention (DAIR) is recommended in early PJI in association with stable implants. The aim of this study was to evaluate the success rate of DAIR in early PJI (<4 weeks) and to identify factors predicting the outcome. Methods: This cohort study included a consecutive series of 35 patients (median age 74 years, 25 women, 26 primary arthroplasties) treated with DAIR for an early PJI in a regional hospital. Results: 28 patients (80%) had their infection eradicated. DAIR-only eradicated the PJI in 22 (63%) patients with a median follow-up of 50 (24-84) months. In 17 (49%) patients, oral AB had been given prior to intraoperative cultures, which delayed first debridement with average 6 days and delayed hospital stay. Primary surgery for a hip fracture increased the risk of DAIR-failure. Surgical experience did not affect the outcome. 17% (n = 6) of the patients sustained a secondary infection during their hospital stay; the majority was beta-lactam resistant coagulase negative Staphylococcus aureus. Conclusions: The success rate of DAIR was inferior to pervious controls from experienced revision centers. Hip fracture patients should be informed about the increased risk of DAIR treatment failure. In order not to delay surgery, empirically based oral AB should not be administered prior to deep cultures.

BACKGROUND: The Swedish Fracture Register (SFR) is a national quality register for all types of fractures in Sweden. Spine fractures have been included since 2015 and are classified using a modified AOSpine classification. The aim of this study was to determine the accuracy of the classification of thoracolumbar burst fractures in the SFR.

METHODS: Assessments of medical images were conducted in 277 consecutive patients with a thoracolumbar burst fracture (T10-L3) identified in the SFR. Two independent reviewers classified the fractures according to the AOSpine classification, with a third reviewer resolving disagreement. The combined results of the reviewers were considered the gold standard. The intra- and inter-rater reliability of the reviewers was determined with Cohen's kappa and percent agreement. The SFR classification was compared with the gold standard using positive predictive values (PPV), Cohen's kappa and percent agreement.

RESULTS: The reliability between reviewers was  high (Cohen's kappa 0.70-0.97). The PPV for correctly classifying burst fractures in the SFR was high irrespective of physician experience (76-89%), treatment (82% non-operative, 95% operative) and hospital type (83% county, 95% university). The inter-rater reliability of B-type injuries and the overall SFR classification compared with the gold standard was low (Cohen's kappa 0.16 and 0.17 respectively).

CONCLUSIONS: The SFR demonstrates a high PPV for accurately classifying burst fractures, regardless of physician experience, treatment and hospital type. However, the reliability of B-type injuries and overall classification in the SFR was found to be low. Future studies on burst fractures using SFR data where classification is important should include a review of medical images to verify the diagnosis.

BACKGROUND AND PURPOSE:  The treatment for patients with thoracolumbar burst fractures without neurological deficit or complete rupture of the posterior ligament complex (PLC) is controversial and includes both surgical and non-surgical options. Current evidence on which treatment is optimal remains inconclusive. In this study we compare surgical with non-surgical treatment. METHODS:  The study is a nationwide, multicenter, register-based randomized controlled trial (R-RCT). Patients with a thoracolumbar burst fracture will be identified by the Swedish Fracture Register. The admitting physician will be notified during the registration process and the patient will be screened for eligibility. Patients, 18 to 66 years old without neurologic deficit to more than a single nerve root and without complete rupture of the PLC, are eligible for the study. 202 patients will be randomized in a 1:1 relation to either surgical or non-surgical treatment. Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI) and radiological data, will be collected at the time of injury, after 3-4 months, and after 1 year. Additional data from national health registries will be collected after 1 year. OUTCOME:  The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data. INTERPRETATION:  The primary outcome is the ODI 1 year after injury. Secondary outcomes include additional PROMs, adverse events, drug consumption, sick leave, healthcare consumption, and imaging data. Estimated duration - The study started on September 1, 2021 and will continue for approximately 4 years. Trial registration - The trial is registered at www.clinicaltrials.com, NCT05003180.

PURPOSE: The aim of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in patients with a spine fracture.

METHODS: Cross-sectional cohort of individuals that had sustained a spine fracture (C1-L5) one year earlier. Patients were asked to fill out SMFA, Oswestry Disability Index (ODI), EQ-5D-3L and EQ-VAS. Spearman's rank correlation coefficient (rho) was used to assess convergent validity for each patient-reported outcome measure (PROM). Bland-Altman plots were used to assess PROM agreement.

RESULTS: 82 patients completed all questionnaires. The correlations between SMFA Dysfunction and Bother indices and ODI were 0.89 and 0.86, with EQ-5D-3L index 0.89 and 0.80, and with EQ-VAS 0.80 and 0.73, respectively. The correlation for separate categories of the SMFA dysfunction index (daily activities, emotional status, arm and hand function, mobility) ranged between 0.71-0.87 for ODI, 0.72-0.84 for EQ-5D-3L index, and 0.67-0.77 for EQ-VAS. A selection of the ten items of SMFA that had the highest correlations with ODI resulted in a correlation of 0.91. The agreements between SMFA indices and ODI in Bland-Altman plots were good with small differential biases and minimal proportional biases, but worse for SMFA and EQ-5D-3L index and EQ-VAS.

CONCLUSION: The SMFA indices are highly correlated with ODI in patients with a spine fracture. The Dysfunction index and Bother index, or selected SMFA items, may be used to assess outcome in patients with spine fractures as an alternative to ODI.

Background and purpose - Postoperative periprosthetic femoral fracture (PPF) after hip arthroplasty is associated with considerable morbidity and mortality. We assessed the incidence and characteristics of periprosthetic fractures in a consecutive cohort of elderly patients treated with a cemented, collarless, polished and tapered femoral stem (CPT). Patients and methods - In this single-center prospective cohort study, we included 1,403 hips in 1,357 patients (mean age 82 (range 52-102) years, 72% women) with primary osteoarthritis (OA) or a femoral neck fracture (FNF) as indication for surgery (367 hips and 1,036 hips, respectively). 64% of patients were ASA class 3 or 4. Hip-related complications and need for repeat surgery were assessed at a mean follow-up time of 4 (1-7) years. A Cox regression analysis was used to evaluate risk factors associated with PPF. Results - 47 hips (3.3%) sustained a periprosthetic fracture at median 7 (2-79) months postoperatively; 41 were comminute Vancouver B2 or complex C-type fractures. The fracture rate was 3.8% for FNF patients and 2.2% for OA patients (hazard ratio (HR) = 4; 95% CI: 1.3-12). Patients > 80 years of age also had a higher risk of fracture (HR = 2; 95% CI: 1.1-4.5). Interpretation - We found a high incidence of early PPF associated with the CPT stem in this old and frail patient group. A possible explanation may be that the polished tapered stem acts as a wedge, splitting the femur after a direct hip contusion. Our results should be confirmed in larger, registry-based studies, but we advise caution when using this stem for this particular patient group.

Purpose: This nationwide study aims to describe the epidemiology, fracture classification and current treatment regimens of olecranon fractures in adults.

Methods: We performed a descriptive study based on registered data from the Swedish Fracture Register (SFR). All non-pathological olecranon fractures reported between 1 January 2014 and 31 December 2018 in patients aged ≥ 18 years were included. Data on age, sex, injury mechanism, fracture classification (according to the modified Mayo classification system), primary treatment and seasonal variation were analyzed. We compared patients < 65 with those > 65 years regarding injury mechanism, distribution of fracture types and subsequent treatment.

Results: In total, 2462 olecranon fractures were identified in the SFR. Median age was 66 years and 65% were women. Of all fractures, 303 (12%) were proximal avulsion, 1044 (42%) simple central, 717 (29%) comminuted central and 398 (16%) distal olecranon fractures. Nonoperative treatment was performed in 21% of the patients < 65 and 35% of the patients > 65 years. Tension band wiring was used for most simple central fractures. Plate fixation was used in almost half of the operatively treated fractures classified as unstable comminuted central and distal olecranon fractures. Men show a higher proportion of high-energy trauma than women in both age groups.

Conclusion: Isolated fractures of the olecranon occur after a low-energy trauma, especially in older women (> 65 years). Non-operative treatment is common in uncomplicated fractures and operative treatment in more complex fractures nationwide. A shift to plate fixation in the more unstable fracture patterns is observed. These results may help health care providers and clinicians gain a better understanding of isolated olecranon fractures.

Background: At least one-third of hip fracture patients have some degree of impaired cognitive status, which may complicate their postoperative rehabilitation.

Aim: We aimed to describe the outcome for elderly patients with cognitive dysfunction operated with hemiarthroplasty (HA) for a femoral neck fracture and to study the impact postoperative geriatric rehabilitation has on functional outcome up to 1 year after surgery.

Methods: 98 patients with a displaced femoral neck fracture with a mean age of 86 years were included and followed up to 1 year. The outcomes were hip-related complications and reoperations, the capacity to return to previous walking ability, health-related quality of life, hip function and mortality.

Results: The prevalence of hip complications leading to a major reoperation was 6% and the 1-year mortality rate was 31%. The lack of geriatric rehabilitation was correlated with poorer outcomes overall and those who receive geriatric rehabilitation were less likely to be confined to a wheelchair or bedridden at the 1-year follow-up.

Conclusions: Hemiarthroplasty is an acceptable option for elderly patients with a displaced femoral neck fracture and cognitive dysfunction. A lack of structured rehabilitation is associated with a significant deterioration in walking ability despite a well-functioning hip. However, the causality of this could be due to selection bias of healthier patients being sent to geriatric rehabilitation.

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.

Background: Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years.

Methods: We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial; all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at threemonths and at one, two, four, eleven, and seventeen years.

Results: The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95% confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64). The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year.

Conclusions: Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality.

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.

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.

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.

BACKGROUND AND PURPOSE: Distal femoral fractures (DFF) in older patients have mortality rates comparable to fractures of the proximal femur. An ageing population combined with an increasing number of patients undergoing total knee arthroplasty (TKA) will make periprosthetic distal femoral fractures (pDFF) more common. We investigated whether a pre-existing TKA influences mortality rates.

PATIENTS AND METHODS: All patients ≥ 60 years registered in the Swedish Fracture Register with a DFF sustained between March 20, 2011 and December 31, 2020 were included. The study cohort comprised 2,725 patients, of which 650 had a pDFF. Unadjusted 90-day and 1-year mortality was estimated via Kaplan-Meier survival curves. A Cox regression model adjusted for age, sex, and treatment modality was used to investigate the association between DFF or pDFF and mortality.

RESULTS: Mean age was 80 years and 82% were females. The most common injury mechanism was a simple fall (75%). The pDFF and DFF group were similar with regards to age, sex, and trauma mechanism. Unadjusted 90-day and 1-year mortality was 11% (95% CI 10-12) and 21% (CI 19-23), respectively. Kaplan-Meier survival analysis demonstrated a slightly lower mortality for pDFFs, especially in patients ≤ 70 years. The Cox regression model showed a lower hazard ratio (HR) for mortality in the pDFF group (HR 0.82, CI 0.71-0.94).

INTERPRETATION: In a large cohort of patients ≥ 60 years with a distal femoral fracture, mortality rates at 90 days and 1 year post-injury were 11% and 21%, respectively. Periprosthetic fractures were associated with a lower mortality.

BACKGROUND AND PURPOSE: Hip fractures should be treated based on the best available evidence and cost-effectively to optimize the outcome for this large group of frail patients. This study examined nationwide variation in surgical methods used for hip fractures.

METHODS: In this cohort study 46,243 patients ≥65 years with a trochanteric hip fracture (THF) or a femoral neck fracture (FNF) registered in the Swedish Fracture Register (SFR) between 1 January 2016 and 31 December 2020 were included. Fractures were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification system. The choice of surgical methods was assessed for each fracture type to compare national variation.

RESULTS: 21,312 THFs and 24,072 FNFs (67% women) with a mean age of 83 years (SD 8) were surgically treated. In the treatment of two-fragment THFs (AO/OTA A1) departments ranged from using 90% short intramedullary nails to 98% sliding hip screws. Treating displaced FNFs (AO/OTA B3), the proportion of hemiarthroplasty ranged from 9 to 90%, and internal fixation between 0.6 to 21%, depending on the department.

INTERPRETATION: A mature national fracture register permits the monitoring of treatment provided and thus serves as an important aid in assessing compliance with guidelines. The large inter-departmental variation in the surgical management of hip fractures in Sweden appears unwarranted based on the current evidence, indicating a need for updated national guidelines. Further research will have to clarify the impact of this variation on mortality and re-operation rates.

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: The sex of the surgeon has been proposed to be associated with a disparity in clinical outcomes after different surgical procedures. We investigated the association between surgeon-patient sex discordance and adverse events (AEs) and surgical AEs (SAEs) within 90 days after primary total hip arthroplasty (THA). We also investigated patient-reported satisfaction with surgical outcomes 1 year after the surgery.

PATIENTS AND METHODS: We conducted a register-based cohort study including primary THAs performed due to osteoarthritis between 2008 and 2016 at 10 publicly managed hospitals in western Sweden. Hospital data was linked to the Swedish Arthroplasty Register and a regional patient register. Logistic regression models investigated discordant sex of patients and surgeons on AEs/SAEs and patient-reported satisfaction with the surgical outcome.

RESULTS:  11,993 primary THAs were included in the study. The proportion of AEs for the concordant group was 7.3% and for the discordant group 6.1%. For SAEs, the proportion was 5.0% for the concordant group and 4.3% for the discordant group. After adjustment the discordant group still had a lower likelihood of an AE or SAE than the concordant group: adjusted odds ratio (aOR) for AE (0.82, 95%CI 0.71-0.95) and for SAE (0.86, CI 0.72-0.99). No association was detected between patient-reported satisfaction and sex discordance.

CONCLUSION: Sex discordance between surgeons and patients is linked to a decreased risk of an AE but not a lower level of patient-reported satisfaction with the surgical outcome.

Purpose: To assess the possibility of using Generative Pretrained Transformer (ChatGPT) specifically in the context of orthopaedic trauma surgery by questions posed to ChatGPT and to evaluate responses (correctness, completeness and adaptiveness) by orthopaedic trauma surgeons.

Methods: ChatGPT (GPT-4 of 12 May 2023) was asked to address 34 common orthopaedic trauma surgery-related questions and generate responses suited to three target groups: patient, nonorthopaedic medical doctor and expert orthopaedic surgeon. Three orthopaedic trauma surgeons independently assessed ChatGPT's responses by using a three-point response scale with a response range between 0 and 2, where a higher number indicates better performance (correctness, completeness and adaptiveness).

Results: A total of 18 (52.9%) of all responses were assessed to be correct (2.0) for the patient target group, while 22 (64.7%) and 24 (70.5%) of the responses were determined to be correct for nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively. Moreover, a total of 18 (52.9%), 25 (73.5%) and 28 (82.4%) of the responses were assessed to be complete (2.0) for patients, nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively. The average adaptiveness was 1.93, 1.95 and 1.97 for patients, nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively.

Conclusion: The study results indicate that ChatGPT can yield valuable and overall correct responses in the context of orthopaedic trauma surgery across different target groups, which encompassed patients, nonorthopaedic medical surgeons and expert orthopaedic surgeons. The average correctness scores, completeness levels and adaptiveness values indicated the ability of ChatGPT to generate overall correct and complete responses adapted to the target group.

Purpose The aims of this study were to assess the function and quality of life after the Total Evolutive Shoulder System (TESS) reverse shoulder arthroplasty (RSA), to evaluate the radiological stability of the stemless version and to address the effect of arm lengthening and scapular notching (SN) on the outcome. Methods This was a prospective comparative non-randomised study. A total of 37 consecutive patients (40 shoulders) underwent TESS RSA between October 2007 and January 2012; 16 were stemless and 26 were stemmed. At a mean follow-up of 39 months (15-66), we evaluated range of motion (ROM), pain and functional outcome with QuickDASH and quality of life with EQ-5D score. Radiologically, component positioning, signs of loosening, SN and arm length difference were documented. Results We found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. No humeral loosening was evident, but there were four glenoid loosenings. In 12 shoulders that developed SN, seven already had scapular bone impression (SBI) evident on initial post-operative radiographs. Glenoid overhang seemed to decrease the risk of SN. Arm lengthening was associated with better EQ-5D but did not influence ROM or functional outcome. Conclusions Reverse shoulder arthroplasty markedly improved shoulder function. SN is of concern in RSA, but proper positioning of the glenoid component may prevent its development.

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.

Aim: To explore the experiences of anaesthesia nurses in assessing postoperative pain in patients undergoing total hip and/or knee arthroplasty.

Methods: Data were collected through four focus group interviews (FGI) using the critical incident technique (CIT). The participants were six men and 12 women, all registered nurses with further education in anaesthesia with at least five-year experience of caring for patients on a postoperative ward.

Results: Maintaining communication with orthopaedic patients, different ways to assess pain, the assessment of unresponsive patients, using pain assessment scales and different work circumstances influencing their use, were stated as the main problems the nurses emphasize while assessing the pain of patients.

Conclusion: Skills related to observing the behaviour and experience of pain in different individuals are needed to ensure an understanding of patients’ pain, as well as the patients’ ability to estimate their pain, where the intensity of the pain varies in different patients. Further studies are needed to examine the way health professionals assess pain, depending on the patients’ ability to transform their pain from a subjective feeling into an objective numeric grade. The way individuals assess their pain differently and the way the resulting knowledge and experience of postoperative care may help nurses and other health-care professionals.

BACKGROUND AND PURPOSE: There are few studies on incidence rates, treatment and outcomes for peri-implant femoral fractures (PIFF) in the proximity of osteosynthesis. The purpose of this study was to investigate the incidence of PIFF following osteosynthesis of proximal femoral fractures.

PATIENTS AND METHODS: This retrospective cohort study comprised a consecutive series of hip fracture patients aged 50 years or older and operated with osteosynthesis between 2003 and 2015. Patients were followed-up until 2018, removal of implants or death, for a mean of 4 years (range 0-15). Data on age, sex, housing, hip complications, and reoperations were recorded. The risk of PIFFs was assessed using Cox proportional hazards regression analysis. In patients with two fractures during the study period, only the first fracture was included.

RESULTS: A total of 1965 osteosynthesis procedures were performed, of which 382 were cephalomedullary nails (CMN), 933 sliding hip devices (SHD) and 650 pins. Mean age was 80 years (range 50-104), 65% of patients were women. A total of 41 PIFFs occurred during the study period. The cumulative incidence of peri-implant fractures was 0.8% for CMN, 2.7% (HR 2.995% CI, 0.87-9.6, p = 0.08) for SHD and 2.0% (HR 2.3 95% CI, 0.6-8.1, p = 0.2) for pins. PIFFs occurred after a mean of 27 months (range 0-143). The 1-year mortality was 34% following PIFF. The majority was treated surgically (66%, 27/41) and the reoperation rate was 15% (4/27).

CONCLUSION: In this retrospective cohort study, in contrast to previous reports, we found a tendency to a higher cumulative incidence of PIFFs for SHD compared to modern CMN. Our results show cumulative incidences of PIFFs comparable to those described for periprosthetic femur fractures after hip arthroplasty for femoral neck fracture.

BACKGROUND: Basic epidemiological data on patella fractures derived from large nationwide and multicenter studies are scarce. This observational register study describes patient epidemiology, fracture classification and treatment of patella fractures in adults in a Swedish population.

METHODS: We conducted an observational study on data derived from the Swedish Fracture Register (SFR) on all patella fractures classified as non-periprosthetic and non-pathological, registered between 2014 and 2018 in individuals aged ≥ 18years. Epidemiological data on sex, age, side, seasonal variation, trauma mechanism, fracture classification (according to AO/OTA), and treatment were analyzed.

RESULTS: 3194 patella fractures were analyzed, occurring at a median age of 67 (range 19-100) years. 64% of all patients were female. Most fractures were caused by low-energy trauma, with 70% due to falling from a standing height. 1796 (56%) of the fractures were transverse compared to 845 (26%) vertical fractures. Most fractures (N=2148, 67%) were treated non-operatively. Operative treatment consisted mainly of Tension Band Wiring (TBW) performed in 774 (24%) patients.

CONCLUSIONS: Patella fractures mainly occur in elderly women (> 65 years), commonly caused by low-energy trauma. The main treatment is non-operative (67%), except for transverse (AO/OTA C3) fractures. TBW remains the most used operative treatment of choice. These results may help health care providers, researchers and clinicians better understand the panorama of patella fractures in Sweden.

BACKGROUND: Although most nondisplaced or minimally displaced femoral neck fractures are routinely treated with internal fixation, high rates of secondary surgical procedures are common, especially in the elderly population. Primary arthroplasty in elderly patients has been proposed as an alternative treatment to reduce the need for a secondary surgical procedure. The objective of this study was to describe the rate of conversion to arthroplasty within 5 years after internal fixation of nondisplaced femoral neck fractures in patients ≥60 years of age.

METHODS: In this observational cohort study of prospectively collected data from the Swedish Fracture Register (SFR) between 2012 and 2018, cross-matched with the Swedish Arthroplasty Register (SAR), 5,428 nondisplaced femoral neck fractures in patients ≥60 years of age were included. Competing risk analysis was used to estimate conversion rates to arthroplasty and mortality in various age groups at 1, 2, and 5 years.

RESULTS: The cumulative incidence function (CIF) for conversion to arthroplasty was 6.3% at 1 year, 8.1% at 2 years, and 10.1% at 5 years. The conversion rates within 2 years were 6.5% in 60 to 69-year-olds, 9.6% in 70 to 79-year-olds, and 7.8% in ≥80-year-olds. Women had a higher risk of conversion; the hazard ratio (HR) was 1.49 (95% confidence interval [CI], 1.19 to 1.87). The cumulative mortality was 21.3% (95% CI, 20.3% to 22.5%) at 1 year, 31.3% (95% CI, 30.0% to 32.6%) at 2 years, and 54.9% (95% CI, 53.1% to 56.7%) at 5 years. Mortality was higher in men at all time points, and the adjusted 1-year HR was 1.79 (95% CI, 1.61 to 2.00).

CONCLUSIONS: One in 10 patients ≥60 years of age treated with internal fixation for a nondisplaced femoral neck fracture underwent conversion to arthroplasty within 5 years, and more than one-half of the conversions occurred within the first year. The risk of conversion was highest in women and in patients 70 to 79 years of age. These data warrant further studies in this frail patient group to identify subgroups of patients who would benefit from primary arthroplasty for nondisplaced femoral neck fractures.

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

BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively.

PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event.

RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register.

CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.

OBJECTIVE: The aim of this study was to assess the association between occupational biomechanical exposures and the occurrence of surgical treatment for subacromial impingement syndrome (SIS).

METHODS: A cohort of 220 295 male constructions workers who participated in a national occupational health surveillance program (1971-1993) were examined prospectively over a 16-year follow-up period (2001-2016) for surgically treated SIS. Worker job title, smoking status, height, weight, and age were registered on health examination. Job titles were mapped to 21 occupational groups based on tasks and training. A job exposure matrix (JEM) was developed with exposure estimates for each occupational group. Surgical cases were determined through linkage with the Swedish national in- and outpatient registers. Poisson regression was used to assess the relative risks (RR) for each biomechanical exposure.

RESULTS: The total incidence rate of surgically treated SIS over the 16-year observation period was 201.1 cases per 100 000 person-years. Increased risk was evident for workers exposed to upper-extremity loading (push/pull/lift) (RR 1.45-2.30), high hand grip force (RR 1.47-2.23), using handheld tools (RR 1.52-2.09), frequent work with hands above shoulders (RR 1.62-2.11), static work (RR 1.77-2.26), and hand-arm vibration (RR 1.78-2.13). There was an increased risk for SIS surgery for all occupational groups (construction trades) compared with white-collar workers (RR 1.56-2.61).

CONCLUSIONS: Occupational upper-extremity load and posture exposures were associated with increased risk for surgical treatment of SIS, which underlines the need for reducing workplace exposures and early symptom detection in highly exposed occupational groups.

We investigated whether patients with lengthening (> 9 mm), restoration (between 9 mm lengthening and 5 mm shortening) or shortening (> 5 mm) of the operated leg after total hip arthroplasty (THA) had different function (WOMAC score), quality of life (EQ-5D), residual hip pain, use of shoe lift and walking aid and leg length discrepancy (LLD) awareness, 12-15 months postoperatively. All patients had a significant postoperative improvement in WOMAC and EQ-5D regardless the LLD. However, the lengthening group showed less improvement in WOMAC, more use of shoe lift, residual hip pain and LLD awareness compared with the other two groups. No differences in EQ-5D were found. In spite of the improvement in function and quality of life, lengthening had adverse effects and should therefore be avoided.

In total hip arthroplasty (THA), radiographic preoperative planning and postoperative evaluation of acetabular component, femoral offset (FO) and leg length discrepancy (LLD) require good validity, interobserver reliability and intraobserver reproducibility. In this study, we evaluated the validity of the Sundsvall method of FO measurement and the interobserver reliability and intraobserver reproducibility of measurement of FO, LLD, acetabular cup inclination and anteversion. Ninety patients with primary unilateral osteoarthritis (OA) were included in this prospective study. On postoperative radiographs FO by the Sundsvall method (femoral axis-pelvic midline), FO by a standard method (femoral axis-hip rotational centre-teardrop point), LLD (inter-teardrop line-lesser trochanter), acetabular cup inclination (on AP view the angle between the cup rim and transischial line) and anteversion (on lateral view the angle between the face of acetabulum and a line perpendicular to the horizontal plane) were measured. The interobserver reliability and intraobserver reproducibility were calculated for three independent observers. The concurrent validity and degree of prediction of the Sundsvall method are measured by comparing its results with the standard method. The interobserver reliability of all measurements was excellent (ICC > 0.80), except for LLD, which was substantial (ICC = 0.79). The intraobserver reproducibility of all measurements was excellent (ICC > 0.80). The concurrent validity of the Sundsvall method compared to the standard method was good with a positive correlation. The Sundsvall method is as reliable as the standard method. The evaluated radiographic measurement methods have the required validity and reliability to be used in clinical practice.

Background and purpose - There is no consensus on the association between global femoral offset (FO) and outcome after total hip arthroplasty (THA). We assessed the association between FO and patients? reported hip function, quality of life, and abductor muscle strength.

Patients and methods - We included 250 patients with unilateral hip osteoarthritis who underwent a THA. Before the operation, the patient?s reported hip function was evaluated with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and quality of life was evaluated with EQ-5D. At 1-year follow-up, the same scores and also hip abductor muscle strength were measured. 222 patients were available for follow-up. These patients were divided into 3 groups according to the postoperative global FO of the operated hip compared to the contralateral hip, as measured on plain radiographs: the decreased FO group (more than 5 mm reduction), the restored FO group (within 5 mm restoration), and the increased FO group (more than 5 mm increment).

Results - All 3 groups improved (p < 0.001). The crude results showed that the decreased FO group had a worse WOMAC index, less abductor muscle strength, and more use of walking aids. When we adjusted these results with possible confounding factors, only global FO reduction was statistically significantly associated with reduced abductor muscle strength. The incidence of residual hip pain and analgesics use was similar in the 3 groups.

Interpretation - A reduction in global FO of more than 5 mm after THA appears to have a negative association with abductor muscle strength of the operated hip, and should therefore be avoided.

Background and purpose - Displaced femoral neck fractures (FNFs) are associated with high rates of mortality during the first postoperative year. The Sernbo score (based on age, habitat, mobility, and mental state) can be used to stratify patients into groups with different 1-year mortality. We assessed this predictive ability in patients with a displaced FNF treated with a hemiarthroplasty or a total hip arthroplasty. Patients and methods - 292 patients (median age 83 (65-99) years, 68% female) with a displaced FNF were included in this prospective cohort study. To predict 1-year mortality, we used a multivariate logistic regression analysis including comorbidities and perioperative management. A receiver operating characteristic (ROC) analysis was used to evaluate the predictive ability of the Sernbo score, which was subsequently divided in a new manner into a low, intermediate, or high risk of death during the first year. Results - At 1-year follow-up, the overall mortality rate was 24%, and in Sernbo's low-, intermediate-, and high-risk groups it was 5%, 22%, and 51%, respectively. The Sernbo score was the only statistically significant predictor of 1-year mortality: odds ratio for the intermediate-risk group was 4.2 (95% Cl: 1.5-12) and for the high-risk group it was 15 (95% CI: 5-40). The ROC analysis showed a fair predictive ability of the Sernbo score, with an area under the curve (AUC) of 0.79 (95% CI: 0.73-0.83). Using a cutoff of less than 11 points on the score gave a sensitivity of 61% and a specificity of 83%. Interpretation - The Sernbo score identifies patients who are at high risk of dying in the first postoperative year. This scoring system could be used to better tailor perioperative care and treatment in patients with displaced FNF.

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.

Purpose: Patients sustaining a hip fracture have a high mortality rate during the first postoperative year and the Sernbo score may stratify patients into a high, intermediate and low risk of death during this period. We assessed its predictive properties on patients from the National Swedish Hip Fracture Register.

Patients and methods: 55,716 hip fracture patients, 69% women older than 65 years at surgery (registered between 2010 and 2015) with complete Sernbo scores and mortality data were studied. Receiver-operating characteristics analyses (ROC) were used. Validation of Sernbo score was performed.

Results: The overall 1-year mortality rate was 26%-and 17%, 27.4% and 55.6% in the low, intermediate and high-risk groups, respectively. The ROC analysis indicated a predictive ability of the Sernbo score, with an AUC of 0.69 (CI 0.68-0.69).

Conclusion: In this registry-based study, the easy-to-use Sernbo scoring system proved to be appropriate and useful way to identify hip fracture patients with a high-risk mortality during the first postoperative year.

BACKGROUND: The purpose of this study was to compare the cumulative incidence of postoperative periprosthetic fracture (PPF) in a cohort of femoral neck fracture (FNF) patients treated with two commonly used cemented stems: either a collarless, polished, tapered Exeter stem or the anatomic Lubinus SP2 stem.

METHODS: In this retrospective multicenter cohort study of a consecutive series of patients, we included 2528 patients of age 60 years and above with an FNF who were treated with either hemiarthroplasty or total hip arthroplasty using either a polished tapered Exeter stem or an anatomic Lubinus SP2 stem. The incidence of PPF was assessed at a minimum of 2 years postoperatively.

RESULTS: The incidence of PPF was assessed at a median follow-up of 47 months postoperatively. Thirty nine patients (1.5%) sustained a PPF at a median of 27 months (range 0-96 months) postoperatively. Two of the operatively treated fractures were Vancouver A (5%), 7 were Vancouver B1 (18%), 10 were Vancouver B2 (26%), 7 were Vancouver B3 (18%), and 13 were Vancouver C (32%). The cumulative incidence of PPF was 2.3% in the Exeter group compared with 0.7% in the SP2 group (p < 0.001). The HR was 5.4 (95% CI 2.4-12.5, p < 0.001), using the SP2 group as the denominator.

CONCLUSIONS: The Exeter stem was associated with a higher risk for PPF than the Lubinus SP2 stem. We suggest that the tapered Exeter stem should be used with caution in the treatment of FNF.

TRIAL REGISTRATION: The study was registered at clinicaltrials.gov (identifier: NCT03326271).

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.

Femoral neck fracture (FNF) is a great challenge for today´s health care and is associated with high mortality and morbidity in the elderly.  In the short term several studies in the literature have demonstrated improved hip function, quality of life and fewer re-operations in elderly patients treated with total hip arthroplasty (THA) instead of internal fixation (IF). There are few reports on the long-term outcome comparing IF and THA. The vast majority of orthopaedic departments in Sweden use the direct lateral (DL) or posteriolateral (PL) approaches for hip arthroplasty. The PL approach has been linked to an increased risk of dislocation of the prosthesis and a higher rate of revision surgery in comparison to the DL approach. There are few reports focusing on radiological risk factors for prosthetic dislocation and patient reported hip function comparing the two surgical approaches for hip arthroplasty in FNF.

The randomized controlled trial (RCT) is the gold standard for evaluating medical or surgical interventions. An RCT of high quality has to be internally and externally valid. Internal validity refers to a correct study design to avoid bias skewing the results. External validity (EV) refers to whether the results will be clinically relevant to a definable group of patients and can be extrapolated to the general health care situation. There are only a few reports in the orthopaedic literature focusing on the EV of published studies and none in the field of hip fractures.

Study I: This is a RCT of 100 patients with a displaced FNF comparing THA and IF. Follow-up evaluations were performed at three months and 1, 2, 4, 11 and 17 years. It was found that the Harris hip score (HHS) was higher and the rate of reoperations lower for patients treated with THA.

Study II: This is a prospective cohort study of 185 hips, comparing the DL and the PL approaches in patients treated with a hemiarthroplasty (HA) for a displaced FNF. Follow-up was after 1 year. There was no difference in patient reported outcome between the groups measured with the HHS and WOMAC index. The PL approach resulted in a higher re-operation rate while the DL approach in a higher incidence of limping.

Study III: This is a retrospective cohort study of 373 patients with a cemented bipolar HA using a PL approach for a FNF with a follow-up ranging from 6 months to 7 years. Radiographs and all surgical records were reviewed regarding femoral offset (FO), leg length discrepancy (LLD) and Wiberg angle. Patients with recurrent dislocations had a decreased postoperative FO, LLD and shallower acetabulum on the operated side compared with their controls.

Study IV: This is a prospective cohort study of 840 hips comparing patients included in a RCT with those that did not give their informed consent (NC) or did not fulfill the criteria for participating in the trial (MS). Patients in the NC and MS groups had an increased mortality rate in comparison to those included in the study. We did not find any differences in hip function between these groups.

The main conclusions of this thesis are:

• Healthy and lucid elderly patients with good hip function preoperatively, should be treated with THA for a displaced FNF.
• The DL approach is favourable in treating displaced FNF with HA due to its decreased risk of reoperation but with an identical hip function outcome as the PL approach.
• Care should be taken to restore the LLD and FO otherwise this may increase the risk of recurrent dislocation of a HA.
• Our findings suggest that trial participants had a lower mortality rate than non-participants but the functional outcome of non-participants appeared to be satisfactory. This is important to take into consideration when extrapolating study results to a health care system.

We investigated whether the Discovery total elbow arthroplasty (TEA) system had good results and survival in rheumatoid arthritis (RA) patients. In a prospective cohort study, one elbow surgeon performed TEA on 25 consecutive RA patients (31 elbows) between December 2004 and November 2012 using the Discovery system. We evaluated the preoperative elbow range of motion (ROM), functional outcome with QuickDash and quality of life with EQ-5D. An independent colleague evaluated the same parameters 1-8 years (mean 4.5) postoperatively. The medical records of the follow-up visits for the study period were available for review. A complete set of results was available for 19 patients (25 elbows). The mean ROM improved in flexion/extension from 88A degrees (SD 27) to 113A degrees (SD 19) and in pronation/supination from 55A degrees (SD 28) to 68A degrees (SD 22) (p < 0.05). The mean QuickDash also improved from 66.5 (SD 25.7) to 40.2 (SD 24) (p < 0.01). The mean EQ-5D improved from 0.68 (SD 0.2) to 0.75 (SD 0.13) but was not statistically significant (p = 0.09). Three patients were revised because of loosening, 2 more patients were re-operated. This resulted in a Kaplan-Meier survival of 90 % (CI 72-97) for the study period. The Discovery system has shown satisfactory results in RA patients even if the rate of complication remained relatively high. Further follow-up is required to investigate the radiological changes observed in some of our patients.

Background: Randomized clinical trials (RCT) are the most reliable way to evaluate theeffect of treatments by comparing them to previously accepted treatment regimes. The resultsobtained from a RCT are extrapolated from the study environment to the general health caresystem. This parameter is called external validity. The present study we sought to evaluatethe external validity of an RCT comparing the results of total hip arthroplasty tohemiarthroplasty in displaced femoral neck fracture in patients 80 years of age and above.

Methods: In a prospective cohort study, 267 patients (76% females, mean age 87 [SD] 4.7years) were included in the cohort study. All were screened according to the inclusion andexclusion criteria to be included in a RCT comparing total hip arthroplasty andhemiarthoplasty. Those who gave their informed consent and were randomized (RCT group,92 patients), those that were asked to participate in the RCT but would not give theirinformed consent (Non-consenters group, 54 patients) and all patients missed in the screeningprocess (Missed screening group, 121 patients). The primary end point was hip functionevaluated with Harris hip score at 1 year. Secondary end points included quality-of-lifeevaluated with EQ-5D mortality and hip re-operations. Follow up was performed at 1 yearpostoperatively by a mailed survey including patient reported outcome.

Results: We did not find any difference between the groups regarding HHS and EQ-5D, alsowhen adjusting for confounders. There was a statistically significant difference between thethree groups (p=0.047) as the Non-consenter group had a higher risk of death than thoseincluded (HR 2.06, 95% Cl 1.13 to 3.75). The rate of reoperation was lower in the MS groupcompared to the RCT and NC groups (4.1% vs 7.6% vs 9.3%). This difference did not reachstatistical significance when adjusting for confounders

Interpretation: This cohort study indicates a higher mortality rate but comparable hip functionand quality-of-life among eligible non-consenters compared to eligible consenters whenevaluating the external validity of a RCT patients with femoral neck fracture age 80 andabove.

BACKGROUND AND PURPOSE: Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF.

STUDY DESIGN: The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.

In this study, the restoration of leg length and global femoral offset and positioning of the femoral stem and acetabular cup of hemiartroplasty (HA) and total hip arthroplasty (THA) after femoral neck fracture (FNF) were compared at the postoperative radiographs between 181 hips operated using the direct lateral (DL) approach and 127 hips operated using the posterolateral (PL) approach. Regarding HA, the DL approach was associated with lengthening of the operated leg (5.7 mm vs. 2.1 mm), p = 0.001. The PL approach had more varus stem position (23% vs. 12%, p = 0.03) and the DL approach had more stems with C-position (58% vs. 32%, p = 0.001). Regarding THA, the DL approach showed increased cup anteversion (28 degrees vs. 21 degrees), p = 0.016, and a decrease in FO (-5.9 mm vs. -2.0 mm, p = 0.04). Surgeons caring for FNF patients are to be aware of the differences in geometrical restroration and component positioning between the two approaches.

INTRODUCTION: Femoral neck fracture (FNF) is a devastating injury with serious medical and social consequences. One-third of these patients have some degree of impaired cognitive status. Despite this, a high proportion of hip fracture trials exclude patients with cognitive impairment (CI). We aimed to evaluate whether moderate to severe CI could predict walking ability, quality of life, functional outcome, reoperations and mortality in elderly patients with displaced FNF treated with hemiarthroplasty (HA).

METHODS: This cohort study included a consecutive series of 188 patients treated with HA for a displaced FNF. Patients were assessed for estimated preoperative and 1 year postoperatively with regard to walking ability, cognitive status, quality of life with EQ-5D and hip function with Harris hip score.

RESULTS: There were 188 patients who met the inclusion criteria. A total of 130 patients were in the control group, and 58 were in the CI group. At 1-year follow-up, 31 patients (24%) had died in the control group and 22 patients (38%) had died in the cognitive impaired group. This difference in reoperation and mortality rate was statistically significant (log-rank test, p = 0.016). The CI had a significantly higher incidence of being non-walker (28 vs. 4%, OR 9.2, p = 0.001). The EQ-5D was higher in the control group, while the Harris hip score was comparable in the two groups.

CONCLUSIONS: Moderate to severe CI was associated with a high incidence of non-walking ability, worse quality of life, high mortality and re-operation rate after femoral neck fractures treated with HA.

Background and purpose The direct lateral (DL) approach to the hip for femoral neck fractures (FNF) has been shown to reduce the rate of dislocation and reoperations. We evaluate the effect of transition from the posterolateral (PL) to DL approach on reoperation and dislocation rates and patients' reported outcome.

Patients and methods In a prospective cohort study between 2012 and 2015, we enrolled 362 patients (median age 83 years, 70% women, mean follow-up 25 months) with a displaced FNF. The first group of 146 patients were operated using the PL and the second group of 216 patients with a DL approach, after change of our routines. A multivariable Cox regression analysis was used to evaluate factors associated with dislocation and reoperation. A generalized linear model was used to evaluate the functional outcome by comparing WOMAC and Harris hip scores between the 2 groups.

Results The reoperation rate was reduced from 13% in the PL to 6% in the DL group and the dislocation rate from 13% to 4%. Cox proportional hazard analysis identified the PL approach as the only factor associated with an increased risk of reoperation (hazard ratio =2.5, 95% CI 1.2-5.2). Age, sex, ASA classification, type of arthroplasty, cognitive dysfunction, or the experience of the surgeon had no effect on the risk of reoperation. Patient-reported outcome was similar between the 2 groups.

Interpretation In patients with FNF we have reduced the reoperation and dislocation rates by changing the surgical approach used for hip arthroplasty without affecting the patient-reported functional outcome.

Purpose To analyze postoperative global femoral offset (FO), leg length discrepancy (LLD) and Wiberg angle as risk factors for prosthetic dislocation after treatment with bipolar hemiarthoplasty (HA) through a postero-lateral approach for femoral neck fracture (FNF). Methods Three hundred and seventy three patients treated with a cemented bipolar HA through a postero-lateral approach between January 2006 and December 2013 were included in a cohort study with a follow-up time ranging from 6 months to 7 years. Radiographs and all surgical records were reviewed regarding Global FO, LLD and Wiberg angle. We compared stable hips without dislocation to those with either a single dislocation and those with recurrent instability. Results Three hundred and twenty eight hips fulfilled the inclusion criteria and were analyzed in the study. The incidence of prosthetic dislocation was 10.7 % (36/373). The mean time from surgery to first dislocation was 3.9 months (0-47) and 62.5 % had recurrent dislocations. Patients with dislocation had a statistically significantly decreased postoperative global FO (-6.4 mm vs. -2.8 mm, p = 0.04), LLD (-2 vs. 1.5 mm, p = 0.03) and smaller Wiberg angle (40A degrees vs. 46A degrees, p = 0.01) on the operated side compared with the rest of cohort. In comparison to age and sex-matched control groups from the cohort, the difference in the radiographic parameters were significant in patients with recurrent dislocations but not in patients with a single dislocation. Conclusion Patients with recurrent dislocations had a decreased postoperative global FO, shorter leg and shallower acetabulum on the operated side compared with their controls. These factors might decrease the soft-tissue tension around the operated hip and predispose to dislocation.

INTRODUCTION: Adopting the direct lateral (DL) instead of the posterolateral (PL) approach in hip arthroplasty for femoral neck fracture (FNF) patients could lower the rate of prosthetic dislocation. However, little is known about how the approach influences the functional outcome.

HYPOTHESIS: We hypothesized that both approaches would give comparable results.

MATERIAL AND METHODS: In a prospective cohort study, we enrolled 185 hips (183 patients, 128 women, median age 84 years) with a displaced FNF. Subjects were assigned to treatment using DL (n=102) or PL approach (n=83) with a hemiarthroplasty (HA). Functional outcome was assessed by Harris Hip Score (HHS), Western Ontario and McMaster Universities Arthritis (WOMAC) index, pain numeric rating scale (PNRS) for pain, mortality and hip complications. Patients were followed-up after 1 year.

RESULTS: The HHS was 71 (SD 18) in the DL group and 72 (SD 17) in the PL group (P=0.59). We found no difference in WOMAC, PNRS and mortality. Seven patients (6.9%) in the DL group and 11 patients (13.3%) in the PL group had undergone a major reoperation (adjusted OR 0.51; 95% CI, 0.18-2.07; P=0.23).

DISCUSSION: In this prospective cohort study, patients treated with HA for FNF using either the DL or PL approaches had comparable functional outcome after 1 year. The PL approach had a tendency towards a higher reoperation rate.

TYPE OF STUDY: Prospective cohort study.

LEVEL OF PROOF: Level 2.

Introduction: Adopting the direct lateral (DL) instead of the posterolateral (PL) approach in hip arthroplasty for femoral neck fracture (FNF) patients could lower the rate of prosthetic dislocation. However, little is known about how the approach influences the functional outcome.

Hypothesis: We hypothesized that both approaches would give comparable results.

Material and methods: In a prospective cohort study, we enrolled 185 hips (183 patients, 128 women, median age 84 years) with a displaced FNF. Subjects were assigned to treatment using DL (n = 102) or PL approach (n = 83) with a hemiarthroplasty (HA). Functional outcome was assessed by Harris hip score (HHS), Western Ontario and McMaster Universities Arthritis (WOMAC) index, pain numeric rating scale (PNRS) for pain, mortality and hip complications. Patients were followed-up after 1 year.

Results: The HHS was 71 (SD 18) in the DL group and 72 (SD 17) in the PL group (P = 0.59). We found no difference in WOMAC, PNRS and mortality. Seven patients (6.9%) in the DL group and 11 patients (13.3%) in the PL group had undergone a major re-operation (adjusted OR: 0.51; 95% CI: 0.18–2.07; P = 0.23).

Discussion: In this prospective cohort study, patients treated with HA for FNF using either the DL or PL approaches had comparable functional outcome after 1 year. The PL approach had a tendency towards a higher re-operation rate.

Type of study: Prospective cohort study.

Level of proof: Level 2.