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  • 1.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 2, p. 743-751Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Despite advances in the care of hip fractures, this area of surgery is associated with high postoperative mortality. Downregulating circulating catecholamines, released as a response to traumatic injury and surgical trauma, is believed to reduce the risk of death in noncardiac surgical patients. This effect has not been studied in hip fractures. This study aims to assess whether survival benefits are gained by reducing the effects of the hyper-adrenergic state with beta-blocker therapy in patients undergoing emergency hip fracture surgery.

    METHODS: This is a retrospective nationwide observational cohort study. All adults [Formula: see text] 18 years were identified from the prospectively collected national quality register for hip fractures in Sweden during a 10-year period. Pathological fractures were excluded. The cohort was subdivided into beta-blocker users and non-users. Poisson regression with robust standard errors and adjustments for confounders was used to evaluate 30-day mortality.

    RESULTS: 134,915 patients were included of whom 38.9% had ongoing beta-blocker therapy at the time of surgery. Beta-blocker users were significantly older and less fit for surgery. Crude 30-day all-cause mortality was significantly increased in non-users (10.0% versus 3.7%, p < 0.001). Beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality (incidence rate ratio 0.28, 95% CI 0.26-0.29, p < 0.001) and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure.

    CONCLUSIONS: Beta-blockers are associated with significant survival benefits when undergoing emergency hip fracture surgery. Outlined results strongly encourage an interventional design to validate the observed relationship.

  • 2.
    Andjelkov, N.
    et al.
    Department of Orthopedics, Västmanlands Regional Hospital, Västerås, Sweden; Centre for Clinical Research, Uppsala University, Västmanlands Regional Hospital, Västerås, Sweden; Department of Orthopaedics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Riyadh, H.
    Department of Orthopedics, Västmanlands Regional Hospital, Västerås, Sweden.
    Ivarsson, Mikael
    Örebro University, School of Health Sciences.
    Kacarevic-Popovic, Z.
    Department of Radiation Chemistry and Physics, Vinca Institute of Nuclear Sciences, University of Belgrade, Belgrade, Serbia.
    Krstic, J.
    Department of Radiation Chemistry and Physics, Vinca Institute of Nuclear Sciences, University of Belgrade, Belgrade, Serbia.
    Wretenberg, Per
    Örebro University, School of Medical Sciences.
    The enhancement of cartilage regeneration by use of a chitosan-based scaffold in a 3D model of microfracture in vitro: a pilot evaluation2021In: Journal of experimental orthopaedics, E-ISSN 2197-1153, Vol. 8, no 1, article id 12Article in journal (Refereed)
    Abstract [en]

    Purpose: Even though various types of scaffolds have been used lately as a complement to microfracture, the exact mechanism of reported cartilage repair improvement when using scaffolds is still unclear. In this study, an effort has been made to identify the specific effects that scaffolds may have on the cells of reparation when using this technique.

    Methods: A 3‑D model in vitro, representing microfracture and containing both chondrocytes and bone marrow‑derived cells in different experimental conditions was made, and the cells were cultured for eight weeks. Subse‑quently, the constructs containing our 3‑D model were removed from the cell culture medium, fixed in paraffin and analyzed with immunohistochemistry.

    Results: Bone marrow – derived cells migrated to the upper compartment of the construct through a perforated nylon membrane containing both enzymatically digested‑ and non‑digested particulated cartilage. The histological sections were stained with hematoxylin, eosin, S‑100, SOX‑9, Gomori, and procollagen type I and II. When minced cartilage wasn’t pretreated with collagenase, exclusively bone‑derived cells have created new extracellular matrix as showed by the histological analysis.

    Conclusions: In this model of microfracture, bone‑derived cells but not chondrocytes have shown to have an active role in new cartilage formation without predigestion with collagenase. Moreover, it seems that the addition of a chitosan‑based scaffold may lead to the improvement of a new cartilage matrix synthesis and integration. This effect hasn’t been seen without the use of scaffold or when a fibrin‑ or a collagen‑based scaffold have been used.

  • 3.
    Andjelkov, Nenad
    et al.
    Department of Orthopedics, Västmanlands Regional Hospital, Västerås, Sweden; Centre for Clinical Research, Uppsala University, Västmanlands Regional Hospital, Västerås, Sweden; Department of Orthopedics, University Hospital Örebro, Örebro, Sweden.
    Riyadh, Hasan
    Department of Orthopedics, Västmanlands Regional Hospital, Västerås, Sweden.
    Wretenberg, Per
    Department of Orthopedics, University Hospital Örebro, Örebro, Sweden.
    Neuralgic and Nociceptive Pain in the Knee as a Cause of the Treatment Failure after Cartilage Repair Surgery: Two Case Reports2018In: Journal of Pain & Relief, ISSN 2167-0846, Vol. 7, no 4, article id 325Article in journal (Refereed)
    Abstract [en]

    Objective: Cartilage injuries are one of the most frequent causes of knee pain. Other causes such as meniscus tears, synovial plica, synovitis, partial and total ligament ruptures are rather easy to identify by standard diagnostic methods and diagnostic arthroscopy. In this study we are describing two other clinical states, which could be the cause of the knee pain and should be addressed before a decision for operative treatment of cartilage injury has been made by a surgeon.

    Materials and Methods: Two patients with isolated focal defects due to previous trauma to the knee were diagnosed both using magnetic resonance imaging preoperatively and intraoperatively during arthroscopy. These were operated arthroscopically with standard procedure for micro fracture. Both patients had treatment failure without a sign of significant improvement after six and twelve months.

    Results: Second look arthroscopy was performed in both cases due to the treatment failure and close to normal cartilage was found in the patella in first case and both in trochlea and medial femoral condyle in other case. No other cause of pain could be identified both with second look arthroscopy and magnetic resonance imaging done 6-12 months postoperatively. The patients were diagnosed with neuralgic pain in one case, and nociceptive pain in other case.

    Conclusion: These states are rare, but have to be addressed by the surgeon before making the decision about the operative treatment. By doing so, one could avoid eventual treatment failure and exposition of the patient to an unnecessary risk of complications during the surgery.

  • 4.
    Bitar, Christian
    et al.
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden.
    Krupic, Ferid
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Felländer-Tsai, Li
    Division of Orthopedics and Biothechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden.
    Crnalic, Sead
    Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Living with a recalled implant: a qualitative study of patients' experiences with ASR hip resurfacing arthroplasty2021In: Patient Safety in Surgery, E-ISSN 1754-9493, Vol. 15, no 1, article id 2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Total hip arthroplasty is the traditional treatment for osteoarthritis in the hip joint. Hip resurfacing arthroplasty, with metal on metal bearing, is a modern concept initially developed mainly for young active people. The metal-on-metal hip arthroplasty implant, Articular Surface Replacement (ASR), was implanted in approximately 93,000 patients before it was recalled in 2010 due to a high complication rate. This study aimed to evaluate patients' own experiences living with an implant that they knew had a high complication rate and had been recalled from the market.

    METHODS: A total of 14 patients, still living with the implant, of a cohort of 34 patients were available for follow-up. Qualitative semi-structured interviews were conducted with 14 patients where a majority actively sought for metal-on-metal hip resurfacing arthroplasty (HRA), and subsequently underwent HRA with an ASR prosthesis between 11/21/2006 and 09/28/2009. The responses were analyzed using content analysis described by Graneheim and Lundman to compress text and identify categories and subcategories.

    RESULTS: The results showed that most patients had already decided that they wanted a metal-on-metal HRA implant before meeting the surgeon. They expressed that the implant made it possible to live an active life. A majority did not think about the fact that they had a hip implant, because they lacked subjective pain. Most of the patients were positive about the annual exams at the hospital and wanted them to continue. None of them felt that their trust towards the healthcare system had changed after the implant recall. They expressed a belief that they would need new surgery sooner than they first thought.

    CONCLUSIONS: Despite all the attention when the ASR prosthesis was recalled, patients with ASR-HRA did not report themselves negatively affected by the recall in this group of patients where a majority had actively sought for an HRA procedure. The healthcare system has an obligation to continue the annual exams, even if the implant provider does not continue reimbursement.

  • 5.
    Bitar, Christian
    et al.
    Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden; Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden.
    Moberg, Ivan
    Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden.
    Krupic, Ferid
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden; Department of Orthopaedics, School of Medical Sciences, Örebro University and Örebro University Hospital, Örebro, Sweden.
    Otten, Volker
    Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden.
    Crnalic, Sead
    Department of Surgical and Perioperative Sciences (Orthopaedics), Umeå University, Umeå, Sweden.
    11-Year outcomes in patients with metal-on-metal ASR hip arthroplasty2022In: Journal of Orthopaedics, ISSN 0972-978X, E-ISSN 2589-9082, Vol. 32, p. 98-103Article in journal (Refereed)
    Abstract [en]

    Background: We analysed the long-term revision rate, clinical outcomes and metal ion concentrations in blood over time in patients who had undergone metal-on-metal Articular Surface Replacement (ASR) hip arthroplasty.

    Methods: A total of 38 patients (43 hips) were included: 24 patients (28 hips) underwent large-head total hip arthroplasty (XL THA), and 14 patients (15 hips) underwent hip resurfacing arthroplasty (HRA). The median follow-up time was 11 (range 7-12) years.

    Results: None of 15 HRA implants were revised. Nine of 28 XL THA implants (32%) in 8 patients were revised. The Co ion levels significantly increased in the XL THA group (p=0.009) over a median time period of 84 (25-97) months.

    Conclusion: The levels of Co ions in blood were higher in the patients who had undergone XL THA and increased significantly over time.

  • 6.
    Burkard, Theresa
    et al.
    ETH Zurich, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Zurich, Switzerland.
    Holmberg, Dag
    Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Thorell, Anders
    Department of Clinical Science, Danderyd Hospital, Karolinska Institutet; Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden.
    Hügle, Thomas
    Department of Rheumatology, Lausanne University Hospital, And University of Lausanne, Lausanne, Switzerland.
    Burden, Andrea M.
    ETH Zurich, Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Zurich, Switzerland.
    The associations between bariatric surgery and hip or knee arthroplasty, and hip or knee osteoarthritis: Propensity score-matched cohort studies2022In: Osteoarthritis and cartilage open, ISSN 2665-9131, Vol. 4, no 2, article id 100249Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the associations between bariatric surgery and hip or knee arthroplasty, and secondary care hip or knee osteoarthritis (OA).

    METHODS: We performed cohort studies using data from Swedish nationwide healthcare registries. Patients aged 18-79 years who underwent bariatric surgery between 2006 and 2019 were matched on their propensity score (PS) to up to 2 obese patients ("unexposed episodes") in risk-set sampling. After a 1-year run-in period, episodes were followed in an "as-treated" approach. Using Cox proportional hazard regression, we calculated hazard ratios (HR) with 95% confidence intervals (CIs) of hip or knee arthroplasty overall and in subgroups of age, sex, joint location, arthroplasty type, bariatric surgery type, and by duration of follow-up if proportional hazard assumptions were violated. In a secondary cohort, we assessed the outcome incident secondary care hip or knee osteoarthritis (OA).

    RESULTS: Among 39'392 bariatric surgery episodes when compared to 61'085 ​PS-matched unexposed episodes (47'594 unique patients), the risk of hip or knee arthroplasty was strongest increased within the first three years of follow-up (HR 1.79, 95% CI 1.56-2.07), decreased thereafter, but remained elevated throughout follow-up. In a secondary cohort of 37'929 exposed when compared to 58'600 ​PS-matched unexposed episodes, the risk of hip or knee osteoarthritis was decreased (HR 0.84, 95% CI 0.79-0.90).

    CONCLUSION: Bariatric surgery is associated with increased risks of hip or knee arthroplasty, but also with decreased risks of secondary care OA. This contradiction supports the hypothesis that bariatric surgery may act as an enabler for hip or knee arthroplasty.

  • 7.
    Edvinsson, Marie
    et al.
    Department of Medical Sciences, Infectious Diseases, Uppsala University, Uppsala, Sweden.
    Welvaart, Nicole
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Ryttberg, Lars
    Department of Orthopaedics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Vikerfors, Tomas
    Department of Infectious Diseases, Örebro University, Örebro, Sweden; Västerås Central Hospital, Västerås, Sweden.
    Nyström-Rosander, Christina
    Department of Medical Sciences, Infectious Diseases, Uppsala University, Uppsala, Sweden.
    No evidence of Chlamydia pneumoniae in the synovia of patients with osteoarthritis2019In: Journal of international medical research, ISSN 0300-0605, E-ISSN 1473-2300, Vol. 47, no 2, p. 635-640Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Osteoarthritis (OA) is a common cause of disability affecting millions of people of all ages worldwide. The pathogenesis involves an inflammatory component, but the cause of the inflammation remains incompletely understood. The intracellular bacteria Chlamydia trachomatis and C. pneumoniae have been demonstrated in patients with reactive arthritis. Both of these microorganisms can cause chronic and persistent infections, with C. trachomatis being the most common cause of reactive arthritis. This study was performed to investigate the presence of C. pneumoniae in a large number of patients with primary OA.

    METHODS: The study included 75 patients who underwent total knee arthroplasty. During surgery, a synovial biopsy was performed and synovial fluid drawn. Real-time polymerase chain reaction (PCR) of C. pneumoniae was run on all patients, and real-time PCR of bacterial 16S rDNA was conducted on 30 of the 75 patients to screen for the presence of other bacteria.

    RESULTS: Real-time PCR showed no evidence of the presence of C. pneumoniae in the patients' specimens, nor were other bacteria detected.

    CONCLUSIONS: Although an inflammatory component is part of the pathogenesis of OA, we found no evidence indicating that C. pneumoniae is a stimulator of that inflammation.

  • 8.
    Eldh, Ann Catrine
    et al.
    Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Joelsson-Alm, Eva
    Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION-a study protocol for a randomised trial by a multi-professional facilitator team and their first-line managers' implementation strategy2021In: Implementation Science, E-ISSN 1748-5908, Vol. 16, no 1, article id 65Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION, project aims to progress knowledge translation vis-à-vis evidence-based bladder monitoring in orthopaedic care, to decrease the risk of urinary retention, and voiding complications. Urinary retention is common whilst in hospital for hip surgery. If not properly identified and managed, there is a high risk of complications, some lifelong and life threatening. Although evidence-based guidelines are available, the implementation is lagging.

    METHODS: Twenty orthopaedic sites are cluster randomised into intervention and control sites, respectively. The intervention sites assemble local facilitator teams among nursing and rehabilitation staff, including first-line managers. The teams receive a 12-month support programme, including face-to-face events and on-demand components to map and bridge barriers to guideline implementation, addressing leadership behaviours and de-implementation of unproductive routines. All sites have access to the guidelines via a public healthcare resource, but the control sites have no implementation support.

    Baseline data collection includes structured assessments of urinary retention procedures via patient records, comprising incidence and severity of voiding issues and complications, plus interviews with managers and staff, and surveys to all hip surgery patients with interviews across all sites. Further assessments of context include the Alberta Context Tool used with staff, the 4Ps tool for preference-based patient participation used with patients, and data on economic aspects of urinary bladder care.

    During the implementation intervention, all events are recorded, and the facilitators keep diaries. Post intervention, the equivalent data collections will be repeated twice, and further data will include experiences of the intervention and guideline implementation.

    Data will be analysed with statistical analyses, including comparisons before and after, and between intervention and control sites. The qualitative data are subjected to content analysis, and mixed methods are applied to inform both clinical outcomes and the process evaluation, corresponding to a hybrid design addressing effectiveness, experiences, and outcomes.

    DISCUSSION: The OPTION trial has a potential to account for barriers and enablers for guideline implementation in the orthopaedic context in general and hip surgery care in particular. Further, it may progress the understanding of implementation leadership by dyads of facilitators and first-line managers.

    TRIAL REGISTRATION: The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021, that is, prior to the baseline data collection.

  • 9.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. School of Medical Sciences, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Peden, Carol J.
    Department of Clinical Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA; Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study2021In: Trauma surgery & acute care open, E-ISSN 2397-5776, Vol. 6, no 1, article id e000778Article in journal (Refereed)
    Abstract [en]

    Objectives: The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.

    Methods: All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.

    Results: 134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.

    Conclusion: An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.

    Levels of evidence: Level III.

  • 10.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 2, p. 709-719Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.

    METHODS: All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00-17:00) and out-of-hours surgery (17:00-08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.

    RESULTS: Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00-1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01-1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04-1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01-1.15), p = 0.022] compared to on-hour surgery.

    CONCLUSION: Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

  • 11.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Ribeiro Jr, Marcelo A. F.
    Pontifical Catholic University of São Paulo, São Paulo, Brazil; Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 3, p. 1467-1475Article in journal (Refereed)
    Abstract [en]

    Purpose: Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

    Methods: All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS & GE; 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

    Results: After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

    Conclusion: Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

  • 12.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Ribeiro, Marcelo A. F.
    Pontifical Catholic University of São Paulo, São Paulo, Brazil; Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 3, p. 1485-1497Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.

    METHODS: This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.

    RESULTS: A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum.

    CONCLUSION: Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

  • 13.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Snwede.
    Borg, Tomas
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 3, p. 1885-1892Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The post-operative mortality after hip fracture surgery is high and has remained largely unchanged during the last decades. The Revised Cardiac Risk Index (RCRI) is a tool used to evaluate the 30-day risk of, among other outcomes, post-operative mortality. The aim of this study is to determine the association between the RCRI score and post-operative mortality in patients undergoing hip fracture surgery.

    METHODS: Data was obtained from the national hip fracture register which was cross-referenced with patients' electronic hospital records. All adults who underwent primary emergency hip fracture surgery in Orebro County, Sweden, between January 1, 2013 and December 31, 2017, were included. Patients were divided into two cohorts: low RCRI (score = 0-1) and high RCRI (score ≥ 2). A Poisson regression model was employed to investigate the association between a high RCRI score and 30- and 90-day post-operative mortality.

    RESULTS: A total of 2443 patients, of whom 446 (18%) had a high RCRI score, were included in the current study. When adjusting for age, sex, comorbidities and type of surgery, the incidence of 30-day mortality increased by 46% in the high RCRI cohort (adj. IRR 1.46, 95% CI, 1.10-1.94, p = 0.010). Similar results were observed for 90-day mortality (adj. IRR 1.50, 95% CI, 1.21-1.84, p < 0.001).

    CONCLUSION: The RCRI is applicable to patients that undergo surgery for traumatic hip fractures. A high RCRI score is associated with an increased incidence of both 30- and 90-day post-operative mortality. Future studies to evaluate these findings are needed.

  • 14.
    Ighani Arani, Perna
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Scandinavian Obesity Surgery Registry, Örebro, Sweden .
    Robertsson, Otto
    Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden; The Swedish Knee Arthroplasty Register, Lund, Sweden.
    W-Dahl, Annette
    Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden; The Swedish Knee Arthroplasty Register, Lund, Sweden.
    Bariatric surgery prior to total knee arthroplasty is not associated with lower risk of revision: a register-based study of 441 patients2021In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 92, no 1, p. 97-101Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Obesity is a considerable medical challenge in society. We investigated the risk of revision for any reasons and for infection in patients having total knee arthroplasty (TKA) for osteoarthritis (OA) within 2 years after bariatric surgery (BS) and compared them with TKAs without BS.

    Patients and methods: We used the Scandinavian Obesity Surgery Registry (SOReg) and the Swedish Knee Arthroplasty Register (SKAR) to identify patients operated on in 2009-2019 with BS who had had primary TKA for OA within 2 years after the BS (BS group) and compared them with TKAs without prior BS (noBS group). We determined adjusted hazard ratio (HR) for the BS group and noBS group using Cox proportional hazard regression for revision due to any reasons and for infection. Adjustments were made for sex, age groups, and BMI categories preoperatively.

    Results: 441 patients were included in the BS group. The risk of revision for infection was higher for the BS group with HR 2.2 (95% CI 1.1-4.7) adjusting for BMI before the TKA, while the risk of revision for any reasons was not statistically significant different for the BS group with HR 1.3 (CI 0.9-2.1). Corresponding figures when adjusting for BMI before the BS were HR 0.9 (CI 0.4-2) and HR 1.2 (CI 0.7-2).

    Interpretation: Our findings did not indicate that BS prior to TKA was associated with lower risk of revision.

  • 15.
    Ighani Arani, Perna
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Scandinavian Obesity Surgery Registry, Örebro, Sweden.
    W-Dahl, Annette
    Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Orthopedics, Lund, Sweden; The Swedish Knee Arthroplasty Register, Lund, Sweden.
    Pain, Function, and Satisfaction After Total Knee Arthroplasty, with or Without Bariatric Surgery2022In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 32, no 4, p. 1164-1169Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The impact of obesity on patient-reported outcome (PRO) after total knee arthroplasty (TKA) surgery has demonstrated varying results. We evaluated knee pain, Activity in Daily Life function (ADL), and satisfaction after TKA surgery in patients with and without prior bariatric surgery (BS).

    METHODS: Scandinavian Obesity Surgery Registry (SOReg) and the Swedish Knee Arthroplasty Register (SKAR) were used to identify patients operated on with primary TKA for osteoarthritis (OA) between 2009 and 2019 that had a BS within 2 years before the TKA (BS group). These patients were compared to patients with TKA without prior BS (no BS group). The patients filled in the Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and one year postoperatively as well as satisfaction with the surgery one year postoperatively. Multiple linear regression analysis was used to evaluate 1-year postoperative KOOS pain and ADL function between the 2 groups. Adjustments were made for sex, age, and preoperative KOOS pain and ADL function respectively.

    RESULTS: Forty-four patients were included in the BS group and 3,525 patients in the no BS group. We found no statistically or clinically significant difference in one-year postoperative KOOS pain and ADL function between the BS group and the no BS group. The majority of the patients in both groups were classified as satisfied or very satisfied one year postoperatively to the TKA.

    CONCLUSIONS: Our results indicate that patients without BS prior to the TKA gain similar 1-year outcome in pain, ADL function and satisfaction as patients with prior BS.

  • 16.
    Ighani Arani, Perna
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Stenberg, Erik
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Scandinavian Obesity Surgery Registry, Örebro, Sweden.
    Ottosson, Johan
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Scandinavian Obesity Surgery Registry, Örebro, Sweden.
    W-Dahl, Annette
    Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, OrthopedicsLund, Sweden; The Swedish Arthroplasty Register, Göteborg, Sweden.
    Total knee arthroplasty and bariatric surgery: change in BMI and risk of revision depending on sequence of surgery2023In: BMC Surgery, E-ISSN 1471-2482, Vol. 23, no 1, article id 53Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patients with obesity have a higher risk of complications after total knee arthroplasty (TKA). We investigated the change in weight 1 and 2 years post-Bariatric Surgery (BS) in patients that had undergone both TKA and BS as well as the risk of revision after TKA based on if BS was performed before or after the TKA.

    METHODS: Patients who had undergone BS within 2 years before or after TKA were identified from the Scandinavian Obesity Surgery Register (SOReg) and the Swedish Knee Arthroplasty Register (SKAR) between 2007 and 2019 and 2009 and 2020, respectively. The cohort was divided into two groups; patients who underwent TKA before BS (TKA-BS) and patients who underwent BS before TKA (BS-TKA). Multilinear regression analysis and a Cox proportional hazards model were used to analyze weight change after BS and the risk of revision after TKA.

    RESULTS: Of the 584 patients included in the study, 119 patients underwent TKA before BS and 465 underwent BS before TKA. No association was detected between the sequence of surgery and total weight loss 1 and 2 years post-BS, - 0.1 (95% confidence interval (CI), - 1.7 to 1.5) and - 1.2 (95% CI, - 5.2 to 2.9), or the risk of revision after TKA [hazard ratio 1.54 (95% CI 0.5-4.5)].

    CONCLUSION: The sequence of surgery in patients undergoing both BS and TKA does not appear to be associated with weight loss after BS or the risk of revision after TKA.

  • 17.
    Ighani Arani, Perna
    et al.
    Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden; Faculty of Medicine and Health, School of Medical Sciences, Örebro University, 702 81, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    W-Dahl, Annette
    Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, 221 00, Lund, Sweden; The Swedish Arthroplasty Register, Göteborg, Sweden.
    Information and BMI limits for patients with obesity eligible for knee arthroplasty: the Swedish surgeons' perspective from a nationwide cross-sectional study2022In: Journal of Orthopaedic Surgery and Research, E-ISSN 1749-799X, Vol. 17, no 1, article id 550Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In the past decades, the incidence of obesity has increased worldwide. This disease is often accompanied with several comorbidities and therefore, surgeons and anesthesiologists should be prepared to provide optimal management for these patients. The aim of this descriptive cross-sectional study was to map the criteria and routines that are used by Swedish knee arthroplasty surgeons today when considering patients with obesity for knee arthroplasty.

    METHODS: A survey including 21 items was created and sent to all the Swedish centers performing knee arthroplasty. The survey included questions about the surgeons' experience, hospital routines of preoperative information given and the surgeons' individual assessment of patients with obesity that candidates for knee arthroplasty. Descriptive statistics were used to present the data.

    RESULTS: A total of 203 (64%) knee surgeons responded to the questionnaire. Almost 90% of the surgeons claimed to inform their patients with obesity that obesity has been associated with an increased risk of complications after knee arthroplasty. Seventy-nine percent reported that they had an upper BMI limit to perform knee arthroplasty, a larger proportion of the private centers had a BMI limit compared to public centers. The majority of the centers had an upper BMI limit of 35.

    CONCLUSION: The majority of the knee arthroplasty surgeons in Sweden inform their patients with obesity regarding risks associated with knee arthroplasty. Most centers that perform knee arthroplasties in Sweden have an upper BMI limit.

  • 18.
    Ivarsson, Mikael
    et al.
    Örebro University, School of Health Sciences.
    Prenkert, Malin
    Örebro University, School of Health Sciences.
    Cheema, Annam
    Department of Health Sciences, University of Örebro, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences.
    Andjelkov, Nenad
    Department of Orthopedics, regional Hospital Västmanland, Västerås, Sweden.
    Mussel Adhesive Protein as a Promising Alternative to Fibrin for Scaffold Fixation during Cartilage Repair Surgery2021In: Cartilage, ISSN 1947-6035, E-ISSN 1947-6043, Vol. 13, no Suppl. 2, p. 663S-671SArticle in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Fibrin has been used as a standard material for scaffold fixation during cartilage repair surgery. Most of the commercially available fibrin preparations need an additional method for scaffold fixation, most often with sutures, thus damaging the surrounding healthy cartilage. There is therefore a need to find alternatives to this method. In our study, we have investigated the potential possibility to use mussel adhesive protein as such an alternative.

    METHODS: In this study, hydrophobic plastic was coated with the mussel adhesive protein Mefp-1 as well as with other cell adhesives (poly-lysine, fibronectin, and collagen). Human keratinocytes and chondrocytes were seeded on these substrates at 37°C in culture medium, followed by analysis of attachment and proliferation by crystal violet staining and metabolic labelling. Performance of Mefp-1 and fibrin as tissue glues were estimated by tensional force resistance measurement of moist porcine dermis (as a correlate to scaffold) glued to dermis, cartilage, or bone at 37°C.

    RESULTS: Mefp-1 supported maximal cell attachment at a coating density of approximately 1 µg/cm2. This was at least as good as the other adhesives tested. In addition, it supported cell proliferation at least as good as regular tissue culture plastic over a 7-day period. Measurement of tensional force resistance showed that Mefp-1 performed equally well as fibrin when porcine dermis was glued to cartilage and bone at the same concentration. Separation of the moist tissues after 15-minute incubation required a force of approximately 1 N/cm2 for both compounds.

    CONCLUSIONS: Mefp-1 show properties that qualify it as a compound that potentially could replace fibrin as a tissue glue for scaffold fixation. Given the possibilities to modify this protein by bioengineering, it is likely that the properties can be further improved.

  • 19.
    Jackwert, Kim
    et al.
    School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Holmér, Michael
    Örebro University, School of Medical Sciences. Department of Geriatrics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hallongren, Matilda
    School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Asmar, Todel
    School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Andersson, Åsa G.
    Örebro University, School of Medical Sciences. Department of Geriatrics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Agreement between Clinical Frailty Scale-scores based on information from patient interviews and Clinical Frailty Scale-scores based on information from medical records: a cross sectional study2024In: BMC Geriatrics, E-ISSN 1471-2318, Vol. 24, no 1, article id 570Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Frailty is an age-related condition with increased risk for adverse health outcomes. Assessing frailty according to the Clinical Frailty Scale (CFS) based on data from medical records is useful for previously unassessed patients, but the validity of such scores in exclusively geriatric populations and in patients with dementia is relatively unknown.

    METHODS: Patients admitted for the first time to one of two geriatric wards at Örebro University hospital between January 1st - December 31st, 2021, were included in this study if they had been appointed a CFS-score by anamnestic interview (CFSI) at admission. CFS scores based on medical records (CFSR) were appointed by a single medical student, who was blinded to the CFSI score. Score-agreement was evaluated with quadratic weighted Cohen's kappa (κ).

    RESULTS: In total, 145 patients between the age of 55-101 were included in the study. The CFSR and CFSI scores agreed perfectly in 102 cases (0.7, 95% CI 0.65-0.77). There was no significant difference regarding age, sex, comorbidity, or number of patients diagnosed with dementia between the patients with complete agreement and the patients whose scores did not agree. Agreement between the scores was substantial, κ = 0.66, 95% CI 0.53-0.80.

    CONCLUSIONS: CFS scores based on information from medical records can be generated with substantial agreement to CFS scores based on in-person anamnestic interviews. A dementia diagnosis does not influence the agreement between the scores. Therefore, these scores are a useful tool for assessing frailty in geriatric patients who previously lack a frailty assessment, both in clinical practice and future research. The results support previous findings, but larger studies are warranted.

  • 20.
    Jakobsson, Hugo
    et al.
    Örebro University, School of Medical Sciences. Department of Hand and Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lundqvist, Eva
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Hand and Orthopedic Surgery.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Hand and Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Hand and Orthopedic Surgery.
    Pulp-to-palm distance after plate fixation of a distal radius fracture corresponds to functional outcome2023In: Archives of physiotherapy, E-ISSN 2057-0082, Vol. 13, no 1, article id 6Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Several factors can influence the outcome after a distal radius fracture (DRF). The aim of this study was to assess whether postoperative pulp-to-palm (PTP) distance correlated with functional outcomes after plate fixation of DRF. MATERIALS &

    METHODS: This is a secondary analysis of a randomized controlled trial aimed to investigate the effects of plate fixation in patients with type-C fractures. Subjects (N = 135) were divided into 2 groups based on PTP distance (equal to or higher than 0 cm) at 4 weeks postoperatively. Outcome measures were collected prospectively at 3, 6 and 12 months and included Patient-Rated Wrist Evaluation (PRWE), Quick Disabilities of the Arm Shoulder and Hand (QuickDASH) scores, wrist range of motion (ROM), Visual Analog Scale (VAS) pain scores, and hand grip strength.

    RESULTS: Overall, at 3 and 6 months patients with PTP > 0 cm had significantly worse outcomes (PRWE, QuickDASH, wrist ROM) than those with PTP =0 cm. At 12 months, QuickDASH and wrist ROM were still significantly worse. In the volar-plating subgroup, patients with PTP > 0 cm had significantly worse wrist ROM and grip strength at 3 months, but no significant differences were found in subsequent follow-ups. In the combined-plating group, patients with PTP > 0 cm had significantly worse QuickDASH, wrist ROM and grip strength at 3 months. At 6 and 12 months, wrist ROM was still significantly worse.

    CONCLUSIONS: Measurement of PTP distance appears to be useful to identify patients likely to have worse outcome after plating of a DRF. This could be a tool to improve the allocation of hand rehabilitation resources.

  • 21.
    Joelson, Anders
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Danielson, Barbro I.
    Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Hedlund, Rune
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Frennered, Karin
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Clinical appearance and reliability in visual assessment after in situ fusion for high-grade isthmic spondylolisthesis2021In: Spine deformity, ISSN 2212-1358, Vol. 9, no 1, p. 155-160Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The current literature on clinical appearance after surgery for high-grade spondylolisthesis is inconclusive. The few long-term comparative studies on surgical reduction versus in situ fusion report contradictory findings concerning appearance-related issues. The purpose of the current study was to evaluate and quantify clinical appearance three decades after in situ fusion for high-grade isthmic spondylolisthesis.

    METHODS: The Scoliosis Research Society (SRS)-22r questionnaire, digital photographs and standing lateral radiographs were used to evaluate clinical appearance for 22 patients three decades after in situ fusion for high-grade spondylolisthesis. The appearance was assessed by two spine surgeons, by the patient themselves, and by quantification of cosmesis relevant radiographic variables including pelvic parameters and sagittal balance.

    RESULTS: The surgeon inter- and intraobserver reliability of the photographic evaluation of the trunk deformity was at most moderate (Cohen's kappa 0.5). Correlation analysis revealed at most medium correlation between radiographic outcome and self-rated (SRS-22r) self-image (Spearman's rank correlation coefficient 0.3). The agreement between patient and surgeon-rated trunk appearance was poor (Cohen's kappa 0.2).

    CONCLUSIONS: Photographic evaluation of the trunk deformity in high-grade spondylolisthesis is unreliable. There were only weak correlations between patient self-assessed trunk appearance and radiographic parameters. The results reflect the pronounced subjectivity of cosmesis, and that the trunk deformity in high-grade spondylolisthesis is not easily observed.

    LEVEL OF EVIDENCE: IV.

  • 22.
    Joelson, Anders
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Danielson, Barbro I.
    Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospital, Gothenburg, Sweden.
    Hedlund, Rune
    Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospital, Gothenburg, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Frennered, Karin
    Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospital, Gothenburg, Sweden.
    Sagittal Balance and Health-Related Quality of Life Three Decades After in Situ Arthrodesis for High-Grade Isthmic Spondylolisthesis2018In: Journal of Bone and Joint Surgery. American volume, ISSN 0021-9355, E-ISSN 1535-1386, Vol. 100, no 16, p. 1357-1365Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: This case series of consecutive patients evaluated sagittal balance and health-related quality of life (HRQoL) 3 decades after in situ arthrodesis for high-grade isthmic spondylolisthesis.

    METHODS: Global sagittal balance, pelvic parameters, and compensatory mechanisms were evaluated on standing lateral radiographs of the spine and pelvis for 28 of 39 consecutive patients, 28 to 41 years after in situ arthrodesis for high-grade L5 to S1 spondylolisthesis. The mean age at surgery was 14 years (range, 9 to 24 years), and the mean age at the time of follow-up was 48 years (range, 39 to 59 years). A subset of the radiographic parameters was compared with the corresponding data from an 8-year follow-up examination of the same patients. HRQoL was evaluated with the Scoliosis Research Society (SRS)-22r questionnaire.

    RESULTS: We found that 3 of the 28 patients had a global sagittal imbalance (T1 spinopelvic inclination of >0°). Signs of compensatory mechanisms, such as reduced thoracic kyphosis and pelvic retroversion, were frequent. There was a significant decrease in sacral slope compared with 8-year follow-up data (p = 0.01). The median SRS-22r subscore was on the same level as Swedish normative data. We found no association between radiographic parameters and SRS-22r outcome.

    CONCLUSIONS: Three decades after in situ arthrodesis for high-grade spondylolisthesis, radiographic signs of noncompensated sagittal imbalance were observed in only a few individuals. The patients had normal SRS-22r scores. There was no association between any radiographic parameter and SRS-22r outcome. The findings are relevant in the controversial discussion on whether to perform a reduction procedure to treat high-grade spondylolisthesis.

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

  • 23.
    Joelson, Anders
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Diarbakerli, Elias
    Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden.
    Gerdhem, Paul
    Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden.
    Hedlund, Rune
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Frennered, Karin
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Self-Image and Health-Related Quality of Life Three Decades After Fusion In Situ for High-Grade Isthmic Spondylolisthesis2019In: Spine deformity, ISSN 2212-134X, Vol. 7, no 2, p. 293-297Article in journal (Refereed)
    Abstract [en]

    STUDY DESIGN: Observational study.

    OBJECTIVES: To evaluate self-image after in situ fusion for high-grade isthmic spondylolisthesis.

    SUMMARY OF BACKGROUND DATA: Certain clinical findings such as short trunk or waistline skin folds are often seen in high-grade spondylolisthesis. Since treatment with spinal fusion in situ does not address appearance, self-image and also health-related quality of life might be negatively affected in the short-term as well as the long-term perspective. This observational study evaluated health-related quality of life outcome including self-image three decades after in situ fusion for high-grade isthmic spondylolisthesis in relation to healthy controls.

    METHODS: Thirty-eight of 39 consecutive patients, fused in situ for high-grade isthmic spondylolisthesis at a young age, completed the Scoliosis Research Society (SRS)-22r questionnaire 28-41 years after surgery. The results were compared with the results of an age- and gender-matched control group.

    RESULTS: We found that the SRS-22r self-image domain scores were statistically significantly lower in patients than in controls whereas the pain and mental health scores were similar in patients and controls. Also, the SRS-22r function domain scores were statistically significantly lower in patients but the difference in means was small. We found no correlation between severity of slip and SRS-22r outcome.

    CONCLUSIONS: In situ fusion for high-grade isthmic spondylolisthesis is a safe treatment option in the long term from a function and pain perspective, but the results of our study suggest that self-image is negatively affected long into adult life.

    LEVEL OF EVIDENCE: Level IV.

  • 24.
    Karlsson, Emma
    et al.
    Department of Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery.
    Björling, Patrik
    Department of Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Hand Surgery.
    Combined volar and dorsal plating vs. volar plating of distal radius fractures: A single-center study of 105 cases2020In: Hand surgery & rehabilitation, ISSN 2468-1229, Vol. 39, no 6, p. 516-521Article in journal (Refereed)
    Abstract [en]

    Despite recent advances in the surgical management of distal radius fractures (DRFs), the optimal treatment remains controversial as different fixation methods often have similar clinical functional and radiographic outcomes. The objective of this study was to assess the differences in outcomes 1 year postoperatively between volar plating and combined plating for DRFs. In a retrospective cohort study, we evaluated 105 consecutive patients operated with either a volar locking plate or combined dorsal and volar plating. The primary outcome was wrist range of motion (ROM). Secondary outcome measures included hand grip strength, visual analog scale (VAS) pain scores, radiographic examination and patient-related outcome measures. Patients treated with combined plating had significantly inferior wrist flexion, extension and ulnar deviation. The radiographic Batra score 1 year postoperatively was similar for both groups. The PRWE (patient-rated wrist evaluation) score was 16 for the volar plating group and 14 for the combined plating group. The QuickDASH (Quick disabilities of the hand arm and shoulder) score was 9 for the volar plating group and 16 for the combined plating group. VAS pain scores were 0 at rest and 2 during activity for both groups. Grip strength was similar between the two groups. Hardware removal was done in 18/78 patients for the combined plating group and 1/27 for the volar plate group. Two patients operated with combined plating had tendon ruptures. Our findings indicate that both methods can yield satisfactory clinical and radiographic outcomes. However, combined plating resulted in inferior wrist ROM and substantially higher frequency of hardware removal. The potential advantages of combined plating in stabilizing a comminuted DRF must be balanced by the potential drawbacks such as inferior wrist ROM and higher frequency of hardware removal.

  • 25.
    Lundqvist, Eva
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Fischer, Per
    Örebro University, School of Medical Sciences. Karlstad Central Hospital, Karlstad, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Krauss, Wolfgang
    Örebro University, School of Medical Sciences. Örebro University Hospital, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Örebro University Hospital, Örebro, Sweden.
    Posttraumatic Arthritis After Combined Plating of Distal Radius Fractures AO Type C: A 7-Year Follow-up of 97 Cases2022In: Hand (New York, N.Y.), ISSN 1558-9447, no Sup. 1, p. 50S-59SArticle in journal (Refereed)
    Abstract [en]

    BACKGROUND: Volar locking plate fixation is the most common method of operative fixation of distal radius fractures (DRFs). For more complex cases, combined plating is an option for stabilizing intra-articular fragments. The prevalence of posttraumatic arthritis (PA) after an intra-articular DRF, and its relation to patient-reported outcome measures (PROMs), remains unclear. The purpose of this study was to study the prevalence of PA and its correlation to clinical outcome measures.

    METHODS: We evaluated 97 consecutive patients with intra-articular DRF, operated with combined plating, 7 years postoperatively. The primary outcome measure was the prevalence of radiographic PA. Secondary outcome measures included visual analog scale (VAS) pain score, hand grip strength, wrist range of motion (ROM), Patient-Rated Wrist Evaluation (PRWE) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographic examination was performed between 1 and 7 years postoperatively.

    RESULTS: The prevalence of PA was 29% at the 7-year follow-up. No correlation was found between PA and ROM, hand grip strength, PRWE, QuickDASH, VAS pain scores, or radiographic reduction. Median wrist ROM and grip strength were significantly inferior compared with the uninjured side. Hardware removal was performed in 51.5% of cases. There were 2 cases of tendon ruptures.

    CONCLUSIONS: Combined plating can yield a good clinical outcome 7 years postoperatively and a low prevalence of PA. The presence of PA did not correlate to clinical outcome measures or to the accuracy of anatomical reduction 1 year postoperatively. The frequency of tendon ruptures was acceptable, but the high frequency of hardware removal is a concern.

  • 26.
    Lundqvist, Eva
    et al.
    Örebro University, School of Medical Sciences. Department of Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Fischer, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, Karlstad Central Hospital, Karlstad, Region Värmland, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Pettersson, Kurt
    Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Region Västernorrland, Sundsvall, Sweden.
    Lopez Personat, Adolfo
    Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases2022In: Journal of Hand Surgery-American Volume, ISSN 0363-5023, E-ISSN 1531-6564, Vol. 47, no 9, p. 813-822Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The optimal way to stabilize intra-articular distal radius fractures is unclear despite recent advances in surgical management. Volar plating is the most common treatment but may not be sufficient for more complex intra-articular AO type C fractures. The purpose of this randomized controlled study was to evaluate the radiographic and clinical outcomes following surgical treatment of AO type C distal radius fractures, comparing volar with combined plating.

    METHODS: In this study, 150 patients were randomized to volar locking plate (n = 75) or combined plating (n = 75) following a distal radius fracture AO type C. The 1-year follow-up included radiographic outcome (Batra score), visual analog scale pain score, hand grip strength, wrist range of motion, Patient-Rated Wrist Evaluation score, and Quick Disabilities of the Arm, Shoulder, and Hand score.

    RESULTS: Overall, 147 patients (median age 61 years) completed the 1-year follow-up (73 patients with volar plate and 74 with combined plating). No difference was found in radiographic outcome between the treatment groups. The volar plate group had significantly better Patient-Rated Wrist Evaluation scores, Quick Disabilities of the Arm, Shoulder, and Hand scores, hand grip strength, visual analog scale scores during activity, and flexion, extension, ulnar and radial deviation than the combined plate group. Hardware removal was performed in 10% in the volar plate group and in 31% in the combined plate group. There was no postoperative infection in the volar plate group but 3 cases in the combined plate group.

    CONCLUSIONS: In patients with complex AO type C intra-articular fractures, volar and combined plating yielded the same radiographic result. The differences in Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores between the groups did not reach the thresholds for minimal clinically important differences, suggesting similar clinical outcome. The combined plating group had a considerably higher frequency of hardware removal and postoperative infections.

    TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

  • 27.
    Lundqvist, Eva
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    Olivecrona, Henrik
    Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    CT-Based Micromotion Analysis After Locking Plate Fixation of AO Type C Distal Radius Fractures2023In: Indian Journal of Orthopaedics, ISSN 0019-5413, E-ISSN 1998-3727, Vol. 57, no 12, p. 2031-2039Article in journal (Refereed)
    Abstract [en]

    Background: Volar locking plate fixation (VLPF) is the most common method for operative fixation of distal radius fractures (DRF). The dorsal ulnar corner (DUC) can be difficult to stabilize as the fragment is small and not exposed when using the volar approach. The purpose of this study was to study fracture fragment migration after VLPF of AO type C DRF, using a volume registration technique of paired CT scans with special focus on the DUC fragment.

    Materials and Methods: This pilot study included ten patients with AO type C DRF, all operated with VLPF. The primary outcome was radiographic outcome. Postoperative and 1-year scans were compared and analyzed. Fragment migration was assessed with CT-based micromotion analysis (CTMA), a software technique used for volume registration of paired CT scans.

    Results: All plates were stable over time. Two patients showed signs of screw movement (0.2-0.35 mm and 0.35- > 1 mm respectively). Postoperative reduction was maintained, and there was no fragment migration at the 1-year follow-up except for one case with increased dorsal tilt. The DUC fragment was found in 8/10 cases, fixated in 7/8 cases, and not dislocated in any case at the 1-year follow-up.

    Conclusion: The CTMA results indicate that variable-angle VLPF after AO type C DRF can yield and maintain a highly stable reduction of the fracture fragments. The DUC fragment remained stable regardless of the number of screws through the fragment. CT volume registration can be a valuable tool in the detailed assessment of fracture fragment migration following volar plate fixation of DRFs.

  • 28.
    Lundqvist, Eva
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery, Örebro University Hospital, Sweden.
    Olivecrona, Henrik
    Department of Molecular Medicine and Surgery, Karolinska Institute, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery, Örebro University Hospital, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery, Örebro University Hospital, Sweden.
    CT-based micromotion analysis of fracture fragment migration after locking plate fixation of AO type C distal radius fracturesManuscript (preprint) (Other academic)
  • 29.
    Lundqvist, Eva
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    Olivecrona, Henrik
    Department of Molecular Medicine and Surgery, Karolinska Institute, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery, Örebro University Hospital, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    CT-based micromotion analysis of fracture fragment migration after locking plate fixation of AO type C distal radius fractures2023In: FESSH-EFSHT 2023 Congress: Abstract Book, 2023, p. 22-23, article id A-0047Conference paper (Other academic)
  • 30.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County, Sweden.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County, Sweden.
    How do orthopaedic surgeons inform their patients before knee arthroplasty surgery?: A cross-sectional study2018In: BMC Musculoskeletal Disorders, E-ISSN 1471-2474, Vol. 19, article id 414Article in journal (Refereed)
    Abstract [en]

    Background: Total knee arthroplasty (TKA) is a successful and common procedure. However, 6–28% of patients are dissatisfied postoperatively. The provision of preoperative patient information, inquiring about patients’ expectations, and taking a psychiatric history are essential parts of both preoperative evaluation and postoperative outcome. The aim of this study was to investigate how orthopaedic knee surgeons in Sweden inform their patients before surgery.

    Methods: A questionnaire was distributed to all knee surgeons performing TKA in Sweden. Responses were received from 60 of the 65 orthopaedic departments performing TKA in Sweden (92%), covering 219 of the approximately 311 knee surgeons at the 65 departments (70%). The answers were analysed with descriptive statistics. A content analysis of the surgeons’ opinions was also performed using a thematic method.

    Results: In terms of information provision, 58% of the surgeons always gave written information while 92% informed orally. Only 44% always asked about the patient’s expectations, and only 42% always informed patients about the 20% dissatisfaction rate after TKA. Additionally, 24% never operated on mild indication of arthrosis, 20% always took a psychiatric history, and half never or seldom consulted a psychiatrist. However, all the knee surgeons believed in a psychiatric impact on TKA outcome. Qualitative analysis revealed five common causes of patient dissatisfaction, which in descending frequency were: patients’ expectations, choice of patients to operate on, surgical factors, combinations of factors, and insufficient information provision to patients.

    Conclusions: Knee surgeons in Sweden have considerable awareness of the importance of preoperative patient information, the impact of patient expectations, and psychiatric illness. However, they need to improve their preoperative routines when it comes to providing written information, asking about the patient’s expectations, and psychiatric assessment.

  • 31.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Preoperative psychological distress no reason to delay total knee arthroplasty: a register‑based prospective cohort study of 458 patients2020In: Archives of Orthopaedic and Trauma Surgery, ISSN 0936-8051, E-ISSN 1434-3916, Vol. 140, no 11, p. 1809-1818Article in journal (Refereed)
    Abstract [en]

    Introduction: Total knee arthroplasty (TKA) is effective in alleviating pain and improving function in patients with knee arthritis. Psychological factors are known to affect patient satisfaction after TKA. It is important to determine the effectiveness of TKA in patients with presurgical anxiety and/or depression to avoid excluding them from surgery.

    Materials and methods: A prospective cohort study was conducted on all patients who underwent TKA during 2016-2018. Patients were divided into four groups: with anxiety, without anxiety, with depression, and without depression. Outcome measures comprised both generic and knee-specific instruments. Each patient group was compared regarding changes in outcome measures one year after surgery. Between-group comparison was also performed.

    Results: Of the 458 patients with complete data, 15.3% and 9.6% had experienced presurgical anxiety and depression, respectively. All patient groups displayed statistical (P < 0.001) and clinical improvement in all outcome measures. Patients with presurgical anxiety and/or depression generally displayed less improvement, though the only significant mean differences concerned the Knee Injury and Osteoarthritis Outcome Score (KOOS)-sport score in the non-anxiety and non-depression groups (P = 0.006 and 0.03, respectively), a higher proportion of clinically improved KOOS pain in the non-anxiety group (P = 0.03), and the general health state in the anxiety and depression groups (P = 0.004 and 0.04, respectively).

    Conclusions: All patients improved in outcome measures 1 year after TKA, regardless of presurgical psychological state. Patients with presurgical anxiety and/or depression benefit greatly from surgery and should not be discriminated against based on presurgical psychological distress, though this fact should not eliminate the preoperative psychological assessment of patients.

  • 32.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Reduction in anxiety and depression symptoms one year after knee replacement: a register-based cohort study of 403 patientsManuscript (preprint) (Other academic)
  • 33.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County Council, Örebro, Sweden.
    Reduction in anxiety and depression symptoms one year after knee replacement: a register-based cohort study of 403 patients2021In: European Journal of Orthopaedic Surgery & Traumatology, ISSN 1633-8065, E-ISSN 1432-1068, Vol. 31, no 6, p. 1215-1224Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Anxiety and depression are associated with patient dissatisfaction after total knee arthroplasty (TKA). Understanding whether preoperative knee-related symptoms could be a cause of anxiety and depression might help prevent unnecessary delay of surgery for this group of patients. We investigated changes in prevalence of anxiety and depression symptoms one year after TKA, and compared demographic data between patients with and without anxiety and depression symptoms preoperatively.

    METHODS: This was a prospective cohort study of 403 patients scheduled for TKA. Data on patient-related outcome measures and the prevalence of anxiety and depression symptoms were collected preoperatively and one year postoperatively. Before-after differences in anxiety/depression prevalence were compared with a chi-square test, and differences in demographic data between the groups with and without anxiety and/or depression symptoms were compared with an independent t test.

    RESULTS: Among the 15% of patients with anxiety symptoms before surgery, 59% had improved in these symptoms one year after surgery; while among the 10% with depression symptoms before surgery, 60% had improved one year after surgery. Patients with preoperative anxiety and/or depression were younger, and had higher body mass index, lower general quality of life (EQ-5D-3L), higher pain scores (visual analog scale), and lower knee-related (KOOS) scores on all subscales except sport.

    CONCLUSION: Presurgical symptoms of anxiety and depression seem to be partly caused by knee symptoms. Understanding of this issue would offer better strategies to prevent unnecessary delay of surgery in this group of patients.

  • 34.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Svantesson, Mia
    Örebro University Hospital. Örebro University, School of Health Sciences. University Health Care Research Center.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Patients’ experiences of discontentment one year after total knee arthroplasty: a qualitative study2020In: BMC Musculoskeletal Disorders, E-ISSN 1471-2474, Vol. 21, no 1, article id 29Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Total knee arthroplasty is a common procedure with generally good results. However, there are still patients who are dissatisfied without known explanation. Satisfaction and dissatisfaction have previously been captured by quantitative designs, but there is a lack of qualitative studies regarding these patients' experiences. Qualitative knowledge might be useful in creating strategies to decrease the dissatisfaction rate.

    METHODS: Of the 348 patients who responded to a letter asking if they were satisfied or dissatisfied with their surgery, 61 (18%) reported discontent. After excluding patients with documented complications and those who declined to participate, semi-structured interviews were conducted with 44 patients. The interviews were analyzed according to qualitative content analysis. The purpose was to describe patients' experiences of discontentment 1 year after total knee arthroplasty.

    RESULTS: The patients experienced unfulfilled expectations and needs regarding unresolved and new problems, limited independence, and lacking of relational supports. They were bothered by pain and stiffness, and worried that changes were complications as a result of surgery. They described inability to perform daily activities and valued activities. They also felt a lack of relational supports, and a lack of respect and continuity, support from health care, and information adapted to their needs.

    CONCLUSION: Patient expectation seems to be the major contributing factor in patient discontentment after knee replacement surgery. This qualitative study sheds light on the on the meaning of unfulfilled expectations, in contrast to previous quantitative studies. The elements of unfulfilled expectations need to be dealt with both on the individual staff level and on the organizational level. For instance, increased continuity of healthcare staff and facilities may help to improve patient satisfaction after surgery.

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    Patients' experiences of discontentment one year after total knee arthroplasty: a qualitative study
  • 35.
    Mohammad Ismail, Ahmad
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study2021In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 133, no 5, p. 1225-1234Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery.

    METHODS: In this retrospective cohort study, all adults who underwent primary emergency hip fracture surgery in Sweden, between January 1, 2008 and December 31, 2017, were included. Patients with pathological fractures and conservatively managed hip fractures were excluded. Patients who filled a prescription within the year before and after surgery were defined as having ongoing BB therapy. The primary outcome of interest was postoperative mortality within the first year. To reduce the effects of confounding from covariates due to nonrandomization in the current study, the inverse probability of treatment weighting (IPTW) method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. These analyses were repeated while excluding patients who died within the first 30 days postoperatively. This reduces the effect of early deaths due to surgical and anesthesiologic complications as well as the higher degree of advanced directives present in the study population compared to the general population, which allowed for the evaluation of the long-term association between BB therapy and mortality in isolation. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI). Statistical significance was defined as a 2-sided P value <.05.

    RESULTS: A total of 134,915 cases were included in the study. After IPTW, BB therapy was associated with a 42% reduction the risk of mortality within the first postoperative year (adjusted HR = 0.58, 95% CI, 0.57-0.60; P < .001). After excluding patients who died within the first 30 days postoperatively, BB therapy was associated with a 27% reduction in the risk of mortality (adjusted HR = 0.73, 95% CI, 0.71-0.75; P < .001).

    CONCLUSIONS: A significant reduction in the risk of mortality in the first year following hip fracture surgery was observed in patients with ongoing BB therapy. Further investigations into this finding are warranted.

  • 36.
    Mohammad Ismail, Ahmad
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients2022In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 92, no 1, p. 49-56Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: An association between beta-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.

    METHODS: All patients over 65 years of age who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥ 4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.

    RESULTS: A total of 126,934 cases met the study inclusion criteria. Beta-blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population [adj. IRR (95% CI): 0.35 (0.32-0.38), p < 0.001]. The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of beta-blocker therapy was seen in patients with an RCRI score greater than 0.

    CONCLUSIONS: Beta-blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of beta-blocker therapy.

    LEVEL OF EVIDENCE: Level II, Therapeutic / Care Management.

  • 37.
    Mohammad Ismail, Ahmad
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Holm, Sebastian
    Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures2020In: Trauma surgery & acute care open, ISSN 2397-5776, Vol. 5, no 1, article id e000533Article in journal (Refereed)
    Abstract [en]

    Background: There is a significant postoperative mortality risk in patients subjected to surgery for hip fractures. Adrenergic hyperactivity induced by trauma and subsequent surgery is thought to be an important contributor. By downregulating the effect of circulating catecholamines the increased risk of postoperative mortality may be reduced. The aim of the current study is to assess the association between regular β-blocker therapy and postoperative mortality.

    Methods: This cohort study used the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in Örebro County, Sweden. Patients with ongoing β-blocker therapy at the time of surgery were allocated to the β-blocker-positive cohort. The primary outcome of interest was 90-day postoperative mortality. Risk factors for 90-day mortality were evaluated using Poisson regression analysis.

    Results: A total of 2443 patients were included in this cohort of whom 900 (36.8%) had ongoing β-blocker therapy before surgery. The β-blocker positive group was significantly older, less fit for surgery based on their American Society of Anesthesiologists classification and had a higher prevalence of comorbidities. A significant risk reduction in 90-day mortality was detected in patients receiving β-blockers (adjusted incidence rate ratio=0.82, 95% CI 0.68 to 0.98, p=0.03).

    Conclusions: β-blocker therapy is associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery. Further investigation into this finding is warranted.

    Level of evidence: Therapeutic study, level III; prognostic study, level II.

  • 38.
    Nerelius, Fredrik
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Sigmundsson, Freyr Gauti
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopaedics.
    Karlén, Niklas
    Department of War Studies and Military History, Swedish Defence University, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Joelson, Anders
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Patient-reported Outcome after Surgical Evacuation of Postoperative Spinal Epidural Hematomas at One-year Follow-up2024In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 49, no 10, p. 701-707Article in journal (Refereed)
    Abstract [en]

    STUDY DESIGN: Retrospective analysis of prospectively collected data from the National Swedish Spine Register (Swespine).

    OBJECTIVE: To evaluate the effects of symptomatic spinal epidural hematoma (SSEH) requiring reoperation on one-year patient-reported outcome measures (PROMs) in a large cohort of patients treated surgically for lumbar spinal stenosis (LSS).

    SUMMARY OF BACKGROUND DATA: Studies exploring the outcomes of reoperations after SSEH are scarce and often lack validated outcome measures. As SSEH is considered a serious complication, understanding of the outcome following hematoma evacuation is important.

    MATERIALS AND METHODS: After retrieving data from 2007 to 2017 from Swespine, we included all patients with LSS without concomitant spondylolisthesis who were treated surgically with decompression without fusion. Patients with evacuated SSEH were identified in the registry. Back/leg pain numerical rating scales (NRS), the Oswestry Disability Index (ODI), and EQ VAS were used for outcome assessment. PROMs before and one-year after decompression surgery were compared between evacuated patients and all other patients. Multivariate linear regression was performed to determine if hematoma evacuation predicted inferior one-year PROM scores.

    RESULTS: A total of 113 patients with an evacuated SSEH were compared with 19527 patients with no evacuation. One-year after decompression surgery, both groups showed significant improvement in all PROMs. When comparing the two groups' one-year improvement there were no significant differences in any PROM. The proportion of patients achieving the minimum important change was not significantly different for any PROM. Multivariate linear regression found that hematoma evacuation significantly predicted inferior one-year ODI (β=4.35, P=0.043), but it was not a significant predictor of inferior NRS Back (β=0.50, P=0.105), NRS Leg (β=0.41, P=0.221), or EQ VAS (β=-1.97, P=0.470). CONCLUSIONS: A surgically evacuated SSEH does not affect outcome in terms of back/leg pain or health-related quality of life. Commonly used PROM surveys may not capture neurologic deficits associated with SSEH.

  • 39.
    Pantzar, Evelina
    et al.
    Department of Orthopedic Sugery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Sugery.
    Riad, Jacques
    Department of Orthopedic Sugery, Örebro University Hospital; Department of Orthopedics, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Skaraborg Hospital, Skövde, Sweden.
    Knee flexion contracture impacts functional mobility in children with cerebral palsy with various degree of involvement: a cross-sectional register study of 2,838 individuals2021In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 92, no 4, p. 472-478Article in journal (Refereed)
    Abstract [en]

    Background and purpose: The impact of knee flexion contracture (KFC) on function in cerebral palsy (CP) is not clear. We studied KFC, functional mobility, and their association in children with CP.

    Subjects and methods: From the Swedish national CP register, 2,838 children were defined into 3 groups: no (≤ 4°), mild (5-14°), and severe (≥ 15°) KFC on physical examination. The Functional Mobility Scale (FMS) levels were categorized: using wheelchair (level 1), using assistive devices (level 2-4), walking independently (level 5-6). Standing and transfer ability and Gross Motor Function Classification (GMFCS) were assessed.

    Results: Of the 2,838 children, 73% had no, 14% mild, and 13% severe KFC. KFC increased from 7% at GMFCS level I to 71% at level V. FMS assessment (n = 2,838) revealed around 2/3 were walking independently and 1/3 used a wheelchair. With mild KFC (no KFC as reference), the odds ratio for FMS level 1 versus FMS level 5-6 at distances of 5, 50, and 500 meters, was 9, 9, and 8 respectively. Correspondingly, with severe KFC, the odds ratio was 170, 260, and 217. In no, mild, and severe KFC 14%, 47%, and 77% could stand with support and 11%, 25%, and 33% could transfer with support.

    Interpretation: Knee flexion contracture is common in children with CP and the severity of KFC impacts function. The proportion of children with KFC rose with increased GMFCS level, reduced functional mobility, and decreased standing and transfer ability. Therefore, early identification and adequate treatment of progressive KFC is important.

  • 40.
    Probert, Noelle
    et al.
    Örebro University, School of Medical Sciences. Centre of Clinical Research, Region Värmland, Karlstad, Sweden.
    Andersson, Åsa
    Örebro University, School of Medical Sciences. Department of Geriatrics.
    Magnuson, Anders
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Kjellberg, Elin
    Department of Infectious Diseases, Central Hospital of Kristianstad, Kristianstad, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Surgical-site infection after hip fracture surgery: preoperative full-body disinfection compared to local disinfection of the surgical site-a population-based observational cohort study2022In: European Geriatric Medicine, ISSN 1878-7649, E-ISSN 1878-7657, Vol. 13, no 5, p. 1098-1097Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Swedish national guidelines recommend full-body disinfection (FBD) with 4% chlorhexidine before hip fracture surgery to prevent surgical-site infection (SSI) despite little evidence. Our objective was to compare preoperative FBD with local disinfection (LD) of the surgical site regarding SSI incidence.

    METHODS: All patients with hip fracture, operated at a hospital in Sweden, January 1, 2018 to December 31, 2019 were included. Patients in 2018 (n = 237) were prepared with FBD and patients in 2019 (n = 259) with LD. Primary outcome was SSI and secondary outcome was SSI and/or death. We adjusted for potential confounders with logistic regression. The adjusted analysis was performed in two models to enable assessment of variables that lacked either outcome; in the first model, these variables were not adjusted, and the second model was restricted to a sub-population not affected by respective variables.

    RESULTS: There were 16 (6.8%) cases of SSI in 2018 and 8 (3.1%) cases in 2019. FBD (2018) compared to LD (2019) presented an adjusted OR of 1.9 (95%CI 0.8-4.9, P = 0.16) respectively 2.0 (95%CI 0.8-5.1, P = 0.14) in the two models of the logistic regression. In addition, 40 (16.9%) patients in 2018 and 29 (11.2%) patients in 2019 had the combined outcome of SSI and/or death, adjusted OR 1.6 (95% CI 0.9-2.8, P = 0.08) respectively 1.7 (95% CI 0.9-2.9, P = 0.06).

    CONCLUSION: We found a non-significant increased risk of SSI 2018 compared to 2019 after adjustment. Randomized control trials are needed. Nonetheless, results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared substantial pain.

  • 41.
    Probert, Noelle
    et al.
    Örebro University, School of Medical Sciences. Department of Radiology and Centre for Clinical Research, Region Värmland, Karlstad, Sweden.
    Blomberg, Karin
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Andersson, Åsa
    Örebro University, School of Medical Sciences. Department of Geriatrics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Traditional compared to modified method of disinfection before hip fracture surgery - Experiences of nursing personnel2023In: International Journal of Orthopaedic and Trauma Nursing, ISSN 1878-1241, E-ISSN 1878-1292, Vol. 49, article id 101002Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: National guidelines in Sweden recommend preoperative full-body disinfection (FBD) with 4% chlorhexidine to prevent surgical-site infection (SSI) after hip fracture surgery, a method causing patients' severe pain. Although, due to little evidence in research, orthopedic clinics in Sweden are wavering in favor of simpler methods such as local disinfection (LD) of the surgical site.

    PURPOSE: The aim of this study was to describe the experiences of nursing personnel regarding the performance of preoperative LD on patients prior to hip fracture surgery after having switched from FBD.

    METHODS: This study has a qualitative design where data were collected via focus-group discussions (FGDs) including in total 12 participants and analysed using content analysis.

    RESULTS: Six categories were identified describing the aim: sparing the patients' physical harm, sparing the patients' psychological distress, involving the patients in the procedure, improving the working environment for personnel, preventing unethical situations and a more adequate utilization of resources.

    CONCLUSIONS: All participants considered LD of the surgical site as a favorable method to FBD, witnessing of an increased wellbeing in patients and the method facilitating a better involvement of patients in the procedure, findings that are supported by other studies promoting person-centered care.

  • 42.
    Probert, Noelle
    et al.
    Örebro University, School of Medical Sciences. Centre of Clinical Research, Region Värmland, Sweden.
    Lööw, A.
    School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Akner, G.
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Andersson, Åsa
    Örebro University, School of Medical Sciences. Department of Geriatrics, Örebro University Hospital, Örebro, Sweden.
    A Comparison of Patients with Hip Fracture, Ten Years Apart: Morbidity, Malnutrition and Sarcopenia2020In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 24, no 8, p. 870-877Article in journal (Refereed)
    Abstract [en]

    Objectives: To investigate possible differences in morbidity, malnutrition, sarcopenia and specific drug use in patients with hip fracture, ten years apart. To analyse 1-year mortality and possible associations with variables.

    Design: A prospective, observational study.

    Setting: Örebro University Hospital, Sweden.

    Participants: Two cohorts of patients with hip fracture, included in 2008 (n=78) and 2018 (n=76).

    Measurements: Presence of comorbidity according to the Elixhauser comorbidity measure, multimorbidity defined as >= 3 comorbidities, preoperative American Society of Anaesthesiologists Classification (ASA-class), malnutrition according to the definition by the Global Leadership Initiative on Malnutrition (GLIM), sarcopenia according to the most recently revised definition by the European Working Group on Sarcopenia in Older People (EWGSOP), polypharmacy defined as >= 5 prescribed medications, use of Potentially Inappropriate Medications (PIM) and Fall-Risk-Increasing-Drugs (FRID) and postoperative 1-year mortality.

    Results: When comparing the cohorts, significant increases over time was seen for mean comorbidity-count (Difference -1; p=0.002), multimorbidity (Difference -15%; 95%CI -27;-2), ASA-class 3-4 (Difference -25%; 95%CI -39;-9) and polypharmacy (Difference -17%; 95%CI -32;-2). Prevalence of malnutrition and sarcopenia coherently decreased with 22% (95%CI 5;37) and 14% (95%CI 1;29) respectively. One-year mortality remained unchanged and a significant association was found for a higher ASA-class in 2008 (OR 3.5, 95%CI 1.1;11.6) when adjusted for age. Results on PIM exposure suggest a decrease while exposure to FRID remained high.

    Conclusion: Our findings support an increasing morbidity within the population over time. However, also presented is a coherent decrease in malnutrition and sarcopenia, suggesting a decrease in frailty as a possible explanation for the observed unaltered mortality, in turn suggesting advances in treatment of comorbidities.

  • 43.
    Reiser, Daniel
    et al.
    Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Fischer, Per
    Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Pettersson, Kurt
    Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    Total Wrist Arthroplasty With a New Design, 20 Cases With 8-Year Follow-Up2023In: Journal of Hand Surgery-American Volume, ISSN 0363-5023, E-ISSN 1531-6564Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Total wrist arthroplasty (TWA) is an established motion-preserving alternative to arthrodesis in the treatment of wrist arthritis, but post-TWA complications requiring additional surgery remain an issue. A new TWA design has been proposed. The purpose of this study was to report the outcome of a cohort study of 20 patients who underwent surgery using the new TWA design.

    METHODS: Patients were assessed before surgery and at 1, 2, and 8 years after surgery for visual analog scale (VAS) pain scores, wrist range of motion, hand grip strength, and patient-reported outcome measures (PROMs). Radiographic examination was conducted for evidence of prosthetic loosening. Reasons for revision were analyzed.

    RESULTS: In total, 24 reoperations were performed, including 12 revisions in 6 patients. Patient-reported outcome measures improved significantly at the 2-year follow-up compared with preoperative values. Hand grip strength, wrist extension, and VAS pain scores improved significantly at the 2-year follow-up. No radiographic loosening of the components was observed, but backing out of the carpal screws was noted in 16 of the 20 cases.

    CONCLUSIONS: The new TWA resulted in improved VAS pain scores, PROMs, wrist extension, and hand grip strength. The high frequency of reoperation is a concern, and modification of the implant is needed.

    TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  • 44.
    Reiser, Daniel
    et al.
    Department of Orthopaedic and Hand Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
    Sagerfors, Marcus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopaedic and Hand Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedic and Hand Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
    Pettersson, Kurt
    Department of Orthopaedic and Hand Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
    Fischer, Per
    Department of Orthopaedic and Hand Surgery, Faculty of Medicine and Health, Örebro University, Sweden; Karlskoga Hospital, Sweden.
    Clinical, Radiographic, and Patient-Perceived Outcome After Radial Hemi-Wrist Arthroplasty With a New Implant: 20 Cases With 5-Year Follow-up2023In: Hand (New York, N.Y.), ISSN 1558-9447, article id 15589447231151427Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Distal component loosening is a common mode of failure in total wrist arthroplasty (TWA). A radial hemi-wrist arthroplasty (RHWA) has the potential to avoid problems related to the distal component in TWA. The aim of this study is to investigate clinical outcomes following surgical treatment with a new RHWA design.

    METHODS: In this pilot study of 20 consecutive RHWAs, patients were assessed preoperatively and postoperatively for range of motion, grip strength, Visual Analog Scale (VAS) pain scores, and functional scoring using Patient-Rated Wrist Evaluation (PRWE), Disabilities of the Arm, Shoulder, and Hand (DASH), and Canadian Occupational Performance Measure. Radiographs were analyzed at 12 months and 5 years (mean, 5.1 years) postoperatively.

    RESULTS: A total of 46 secondary surgeries were undertaken in 16 wrists, including 7 revisions. Another 6 patients are waiting for revision to radiocarpal arthrodesis. In non-revised patients, the DASH and PRWE scores improved, and wrist range of motion remained largely unchanged except for wrist flexion, which decreased. The VAS pain score during activity was reduced, and hand grip strength remained largely unchanged.

    CONCLUSIONS: The new implant resulted in improved functional scoring and improved VAS pain scores in non-revised patients, but many cases needed secondary surgery due to persistent pain. The high revision rate is a major concern, and further use of the implant in its current form cannot be recommended.

  • 45.
    Riyadh, Hasan
    et al.
    Department of Orthopaedics, Västmanlands Regional Hospital, Västerås, Sweden.
    Andjelkov, Nenad
    Department of Orthopaedics, Västmanlands Regional Hospital, Västerås, Sweden; Centre for Clinical Research, Uppsala University, Västmanlands Regional Hospital, Västerås, Sweden; Department of Orthopaedics, University Hospital Örebro, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Parameters identifying the risk of treatment failure after cartilage repair: a proposed treatment algorithm and pilot study2019In: Current Opinion in Orthopaedics, ISSN 1940-7041, Vol. 30, no 4, p. 327-331Article in journal (Refereed)
    Abstract [en]

    Background: Cartilage defects often are treated with different techniques depending on the surgeon's preferences and technical availability. A more systematic approach is therefore needed as a practical guide for surgeons regarding the choice of a suitable treatment for a particular patient.

    Methods: A retrospective descriptive study was done on 40 patients operated on with one of the following techniques: arthroscopic microfracture, periosteal transplantation and assisted matrix induced chondrogenesis (AMIC) technique. The average age of patients was 30.5 yr, with a minimum of 12 and a maximum of 54 yr. The average size of the injury was 2.67 cm(2), with a minimum of 1 cm(2) and a maximum of 6 cm(2). The distribution of the injuries was as follows: trochlea 22.5%, medial femoral condyle 45%, patella 30%, and lateral femoral condyle 2.5%.

    Results: The proportion of patients who were not satisfied was 21% after 1-year follow-up. The proportion of reoperated patients was 12.5%. The proportion of patients operated on previously was 12.5%. The proportion of patients with multiple chondral defects was 7.5%. Younger patients fared better.

    Conclusions: Microfracture as the primary technique led to the most failures, but because of its simplicity and balanced clinical results, it should be used as the gold standard, especially in younger patients. Open techniques, AMIC, and periosteal transplantation should be reserved as second choice treatments after failure and as a first choice treatment for multiple lesions, larger defects, older patients, and for defects such as osteochondritis dissecans where there is a need for autologous cancellous bone transplantation.

  • 46.
    Sagerfors, Marcus
    et al.
    Department of Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Jakobsson, Hugo
    Department of Orthopedics and Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Thórdardóttir, Ásgerdur
    Department of Hand Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Möller, Michael
    Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register2022Conference paper (Other academic)
  • 47.
    Sagerfors, Marcus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    Jakobsson, Hugo
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery.
    Thórdardóttir, Ásgerdur
    Department of Orthopedics and Hand Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery.
    Möller, Michael
    Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden.
    Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register2022In: BMC Geriatrics, E-ISSN 1471-2318, Vol. 22, no 1, article id 140Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The distal radius fracture (DRF) is the most common fracture in adults. With an ageing population, the number of wrist fractures in the superelderly (≥ 80 years) is expected to rise. Optimal treatment for displaced DRFs remains controversial, especially in the superelderly group. In addition, basic knowledge of the outcome after a DRF in this heterogenic group is lacking. The aim of this study was to study injury characteristics, treatment and outcome of DRFs in superelderly patients using data from a large national register.

    METHODS: We used prospectively collected data from the Swedish Fracture Register. All distal radius fractures registered between April 2012 and December 2018 in patients ≥ 80 years of age were included. Data on epidemiology, fracture type, trauma mechanism and treatment are registered by the physician treating the patient. Patients are also sent a subjective outcome questionnaire including EQ-5D, EQ-VAS and Short Musculoskeletal Function Assessment questionnaire (SMFA-score) at the time of injury and after 12 months. The 12-month questionnaire was sent to those who had completed the questionnaire at the time of injury. A Mann-Whitney U-test was used to assess differences between treatment methods.

    RESULTS: Mean age for this population was 86 years (80-105 years), a majority of the patients were female (86.7%). The dominating injury mechanism was a simple fall (74.6%) in the patient's residence. The majority of fractures were AO type A (70%) followed by AO type C (20.9%) and type B (8.6%). The incidence of open fractures was significantly higher in females (2.6%) compared to males (1.5%). A majority of the fractures were treated with a cast (87.5%) with volar locking plate as the second most common treatment method (6.6%). Patient-reported outcome measures (PROMs) EQ-5D, EQ-VAS and the Arm Hand Function Index of the SMFA-score deteriorated somewhat one year after injury compared to pre-injury. PROMs did not correlate to treatment with cast or a volar plate.

    CONCLUSIONS: This nationwide register study provides detailed data on DRFs in the superelderly regarding epidemiology, treatment and self-reported outcome. A good self-reported outcome is possible, but many patients do not recover completely. PROMs did not correlate to type of treatment. The frequency of open fractures was significantly higher in females. The reason for this is unclear but different skin thickness in older males versus females may be one explanation.

  • 48.
    Sagerfors, Marcus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Jakobsson, Hugo
    Örebro University, School of Medical Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences.
    Distal Radius Fracture AO type C, Treatment and Outcome. An Observational Study of 12,199 Fractures from the National Swedish Fracture Register2022In: AAHS 2022 American Association of Hand Surgery, 2022Conference paper (Other academic)
  • 49.
    Sagerfors, Marcus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics and Hand Surgery.
    Jakobsson, Hugo
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedics and Hand Surgery.
    Brus, Ole
    Örebro University, School of Medical Sciences. Clinical Epidemiology and Biostatistics unit.
    Möller, Michael
    Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg. Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden.
    Treatment and outcome of AO/OTA type C distal radius fractures: 12 199 fractures from the Swedish Fracture Register2023In: Acta Orthopaedica Belgica, ISSN 0001-6462, Vol. 89, no 2, p. 241-247Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to examine the epidemiology, treatment, and patient-reported outcome of AO/OTA type C distal radius fractures (DRF) using data from a large national fracture register. We used prospectively collected data from the Swedish Fracture Register covering all AO/OTA type C DRFs registered between April 2012 and December 2018. Data on fracture type, epidemiology, trauma-mechanism, and treatment had been recorded by the treating physician. Patients had been sent an outcome questionnaire including EQ-VAS, EQ-5D, and the SMFA at the time of injury and 12 months after. A total of 12 199 cases with AO/OTA type C fracture were identified. AO/OTA type C1 fracture was most common, with 5400 cases, followed by AO type C2 with 4304 and AO/OTA type C3 with 2495. Cast treatment and surgical treatment with volar locking plate fixation were the most common treatments. Patient-reported outcome measures worsened significantly one year after the fracture, and 56% reported moderate problems with pain and discomfort one year after the fracture. Patients treated with a volar plate reported a significantly larger deterioration in EQ-5D outcome compared to patients treated with a cast. No treatment method was found to be superior. A good outcome after a type C fracture is possible, but many patients do not recover completely. Our findings indicate a relatively better self-reported outcome for patients treated with a cast, but as treatment was not randomized the clinical relevance is unclear.

  • 50.
    Sandberg, Olof
    et al.
    Sectra AB, Linköping, Sweden.
    Carlsson, Sofia
    Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Harbom, Ellen
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Cappelen, Vendela
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Tholén, Simon
    Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Olivecrona, Henrik
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Medical Sciences, Section of Orthopaedics, Örebro University Hospital, Örebro, Sweden.
    Inducible displacement CT increases the diagnostic accuracy of aseptic loosening in primary total hip arthroplasty2022In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 93, p. 831-836Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Inducible displacement CT compares 2 CTs acquired in series but with alternated rota-tion of the femur. This provides visual and quantitative clues as to the mechanical situation, i.e., loosening, of a total hip arthroplasty. We report the accuracy of this method as well as the experience of integrating it into a clinical workflow.

    Patients and methods: This was a retrospective single centre study of 72 cases of suspected aseptic loosening were the surgeon after reviewing a standard plain radiograph saw a need for more information. The displacement CT and plain radiograph were compared either to intraoperative findings or a 1-3 year follow up questionnaire for patients that did not have revision surgery. Patients reporting degradation in status since the time of the displacement CT were called for a follow up plain radiograph. Sensitivity and specificity were assessed, and user experience gathered.

    Results: Of 72 enrolled patients 15 were lost to follow-up. Of the remaining 57, 17 were judged by in-traoperative findings or follow-up to have had loose implants. For plain radiography the sensitivity and specificity were 59% (95% CI 35-82) and 85% (74-96). For displacement CT the cor-responding values were 77% (56-97), and 100% (100-100) respectively. The tool was adaptable to clinical routine.

    Conclusion: Displacement CT with alternated rota-tions of the femur is a viable option to improve the diag-nostic process for identifying aseptic loosening in a total hip arthroplasty.

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