To Örebro University

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.

BACKGROUND: Pelvic ring fractures caused by high-energy trauma are severe injuries with well described radiological and clinical outcomes, whereas description from the patient's perspective is less well documented. The purpose of this study was to investigate patient-reported outcome following surgical treatment of pelvic fractures using quality of life instruments.

METHODS: All 54 patients (28 male/26 female, ages 16-68) with pelvic fractures referred to our institution for surgical treatment 2003-2005 were prospectively included. The most common trauma was motor vehicle accident (44%). Additional injuries were seen in 74% and in 31% the ISS was >or=16. There were 31 B and 23 C type fractures. Patients were followed for two years using two validated questionnaires, SF-36 and LiSat-11, the latter an instrument consisting of 11 questions for evaluation of satisfaction with different aspects of life.

RESULTS: 45 patients could be followed according to the study protocol for two years while 2 were untraceable and 1 died from unrelated causes. Of 6 nonresponders, 5 were unable due to psychiatric disorder. At two years pelvic fracture patients scored lower than the reference population in both physical and mental domains (SF-36). Highest mean score, 68, was in the domain Social Function (norm 89) while lowest mean score, 38, was in the domain Role Physical (norm 86). The mean score closest to the normative was for general health with 61 for patients and 78 for the normative group. In LiSat-11 pelvic fracture patients scored lower than the reference population in all areas. Satisfaction with life as a whole was 31% compared with 60% in the normative group.

CONCLUSIONS: Two years after surgical treatment of pelvic ring fractures, patients reported substantially lower quality of life for both physical and mental domains, when compared with a reference population, even when radiological and clinical outcomes were considered favourable.

OBJECTIVE: The aim of this study was to determine quality of life (QoL) changes over time after internal fixation of acetabular fractures.

DESIGN: This pertains to a prospective cohort study, which was single centered.

SETTING: The study was conducted at the University Hospital.

PATIENTS: One hundred thirty-six patients (108 men, 28 women), age 17-83 years operated for an acetabular fracture during 2004-2008 were prospectively included and followed up for 2 years.

MAIN OUTCOME MEASURES: QoL was evaluated via Short Form-36 (SF-36) and Life Satisfaction-11 at 6, 12, and 24 months. Radiographs were evaluated according to Matta at 2 years.

RESULTS: The most frequent fracture types were posterior wall (n31), associated anterior-posterior hemitransverse (n34), and associated both column (n29). One hundred twenty-nine patients could be assessed at 2 years, 4 did not respond, and 3 had died. The patients scored lower than norms in all 8 SF-36 domains with improvement over time for Physical Function (P < 0.0001) and Role Physical (P < 0.0001). The patients with postop reduction 0-1 mm scored better (P < 0.001-0.039) in 7 domains, all except vitality (P = 0.07), when compared with patients with residual displacement of ≥2 mm. Life satisfaction did not change with time and showed lower scores than normative in 9 of 11 items. Nineteen patients had undergone total hip replacement, and the strongest predictor was acetabular or femoral head impaction.

CONCLUSIONS: QoL in surgically treated patients with displaced acetabular fracture keeps improving in physical SF-36 domains over a 2-year period although still lower than norms, and anatomical reduction results in better QoL outcome in most dimensions.

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

PURPOSE: To construct a questionnaire to assess outcomes in patients who underwent internal fixation for acetabular fractures.

METHODS: 27 female and 100 male consecutive patients (mean age, 50 years) who underwent internal fixation for acetabular fractures were included. Patients were asked to report their outcomes at months 6, 12, and 24 using a questionnaire. The initial questionnaire was constructed by an expert group. There were 11 closed questions, each came with 6 responses from ?no discomfort? to ?very severe discomfort?. Three open questions were added to cover topics that were not included. The content validity and relevance of the 11 closed questions was determined using factor analysis to determine the number of factors involved. Factorability of the correlation matrix was measured via the Bartlett test of sphericity and Kaiser-Meyer- Olkin (KMO) measure of sampling sufficiency. Factor loadings of <0.50 were considered acceptable for factor representation. Reliability in terms of internal consistency was expressed as Cronbach alpha coefficients. The responses to the 3 open questions were analysed and categorised by a single assessor.

RESULTS: 120 (94%) of the patients completed at least one questionnaire, and 92 (72%) completed all 3 questionnaires during the follow-up period. Based on responses to the 6-month questionnaire, responses to the 11 closed questions were significantly intercorrelated (Spearman 0.17-0.80). After factor analysis and analysis of responses to open questions, the number of questions was reduced to 6 and included questions related to pain, walking, hip motion, leg numbness, sexual life, and operation scar. Reliability of the questionnaire was estimated to alpha=0.89. Criterion validity was adequate with a high correlation with the Short Form 36 (r=0.56-0.80).

CONCLUSION: Patients treated with acetabular fractures can be adequately assessed using the 6-item questionnaire and one global question concerning impact on activities of daily living.

INTRODUCTION: The aim of this study was to evaluate functional outcome after surgically treated acetabular fracture using radiography and patient-reported outcome measures, and to determine predictors of hip joint failure 5 years post-surgery.

PATIENTS AND METHODS: All patients with acetabular fractures treated with open reduction and internal fixation (ORIF) at our unit are prospectively entered into a local register. 101 acetabular fractures in 112 patients treated from 2004 to 2007 were eligible for analysis 5 years after surgery. Radiographs and questionnaires regarding physical function (Short Form[SF]-36) and pelvic discomfort index (PDI, 100 % = worst outcome) were obtained. The primary outcome measure was "joint failure" defined as either secondary total hip arthroplasty (THA) or a Girdlestone situation. Univariable analysis was used to compare patients with joint failure to those without, and binary logistic regression analysis was performed to identify risk factors of joint failure.

RESULTS: 77 % of 101 followed patients had a preserved hip joint 5 years after surgery, and failure of the hip joint most often occurred within the first 2 years after injury. Patients with preserved hip joints had higher scores in the SF-36 physical function domain (median 75 vs. 48; p = 0.004) and better PDI (28 vs. 43 %, p = 0.03). Femoral head impaction was associated with an increased risk of joint failure [relative risk (RR) = 15.2, 95 % CI 3-95; p = 0.002], as was an age of ≥60 years at the time of injury (RR = 4.2, CI 1.3-15; p = 0.02).

CONCLUSIONS: Patients with failed hip joints after surgery for acetabular fracture have inferior global and disease-specific functional outcomes, even after secondary arthroplasty surgery. We suggest that patients with predictors of joint failure could benefit from other treatment strategies than ORIF, and primary insertion of THA may be an alternative treatment strategy for this subgroup.

AIMS: Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called 'combined hip procedure' (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone.

PATIENTS AND METHODS: A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed.

RESULTS: No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes.

CONCLUSION: The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP.

PURPOSE: To develop a pelvic discomfort index (PDI) to evaluate outcome following fixation for pelvic ring injury.

METHODS: 29 female and 44 male consecutive patients (mean age, 36 years) underwent internal fixation for pelvic ring injury of type B1 (n=10), B2 (n=22), B3 (n=15), C1 (n=18), C2 (n=5), and C3 (n=3), based on the AO/OTA classification. At postoperative 6, 12, and 24 months, patients were asked to assess their discomfort in the pelvis using a 14-item questionnaire. Three questions were open-ended, and responses were categorised by a single assessor. The remaining 11 questions were closed-ended and had 6 ordinal options from 'no discomfort' (score=0) to 'extremely severe discomfort' (score=5). The content validity and relevance of the 11 closed-ended questions was determined. The 14-item questionnaire was compared with the 36-item Short Form Health Survey (SF-36).

RESULTS: Respectively at postoperative 6, 12, and 24 months, 78%, 71%, and 71% of the patients completed the 14-item questionnaire. Based on the factor analysis and responses to the open-ended questions, the number of items was reduced to 6 including pain, walking, mobility of the hips, loss of sensation in the legs, sexual life, and operation scar. Four factors could explain 96% of the total variance. The first factor involved the first 3 items (pain, walking, and hip motion) and addressed 'pelvis', whereas 3 factors involved the remaining items and each addressed peripheral neurology, sexual life, and operation scar. A PDI was developed using these 6 items. The PDI had high internal reliability (α=0.89), adequate content and criterion validity, and moderate correlation with the SF-36 total score or scores of physical function, bodily pain, and general health (r=0.50-0.77).

CONCLUSION: The PDI provides valid, specific, and relevant information to assess outcome following fixation for pelvic ring injury.

BACKGROUND AND AIMS: jumping from great height is an aggressive method of suicide attempt where the frequent combination of psychiatric disorder and somatic injuries makes treatment difficult. Our aim was to evaluate survival rate and get patient-reported outcome in patients operated for a pelvic or acetabular fracture sustained when jumping from a height as a suicide attempt.

PATIENTS AND METHODS: during the period 2003-2004, 12 patients (11 women) of whom eight were below 30 years of age, were prospectively included. At two years HRQoL (Health-Related Quality of Life) questionnaires (SF-36 and LiSat-11) were used to describe outcome, and at four years a structured psychiatric interview SCID-I (Structured Clinical Interview for DSM-IV Axis I Disorders) was done.

RESULTS: at four years all patients were alive. One patient had made a new suicide attempt. Eight patients gave adequate reply on SF-36 and LiSat-11 at two years. In all domains patients scored lower than a norm group with the relatively lowest values in physical domains. Younger patients assessed life as better when compared with middle aged patients.

CONCLUSIONS: this study showed a very low recurrence rate into suicidal behaviour in a group of jumpers and all patients were alive at four years after a suicidal attempt by jumping. The high proportion of psychiatric disorder in these patients highlights the need for a combined treatment effort between orthopaedic and psychiatric expertise.

We describe the surgical technique and report the outcome after closed reduction and percutaneous plating in 21 closed extraarticular distal tibial fractures using titanium LC-DCP. A long plate was pushed subcutaneously through a small incision at the medial malleolus and fixed with screws through stab incisions. Fracture reduction was anatomical or nearly anatomical without angular displacement in 14 cases, and considered acceptable in four cases. Two patients were reoperated because of malreduction. Seventeen fractures healed within 6 months. There were two delayed unions, and two non-unions. There were two deep infections, both in diabetic patients. Follow-up by an independent observer at on average 14 (5-25) months showed various symptoms such as slightly reduced ankle mobility (9/20), reduced walking ability (11/20) or tenderness around the plate (11/20). No patient complained of knee symptoms related to the surgery. Operative treatment of closed distal tibial shaft fractures with a long titanium plate provided good anatomical results and allowed in most patients early weight-bearing. In patients with soft tissues in good condition and no risk factor for infection percutaneous plate osteosynthesis might become an attractive treatment option for fractures in the distal tibia.

BACKGROUND AND AIMS: The aim of this retrospective study was to analyze retention in cast after closed reduction of low-energy two-fragment tibial shaft fractures.

MATERIAL AND METHODS: The material consisted of 72 closed tibial shaft fractures AO/ ASIF type A treated with closed reduction and plaster cast. Fractures were subgrouped according to the AO/ASIF classification and the initial fracture displacement was measured. Final alignment and the frequency of operative intervention due to early loss of reduction were analyzed.

RESULTS: 40% of all fractures lost reduction and were operated on. The largest subgroup was A1.2 fractures, a spiral tibial shaft fracture with a fibular fracture at another level. Out of the 28 fractures in this group 61% were converted from cast to early operative intervention.

CONCLUSION: Closed reduction and cast treatment of spiral tibial shaft fractures AO/ ASIF type A1.2 had a high failure rate.

Hip fracture patients have a high risk of mortality after surgery, with 30-day postoperative rates as high as 10%. This study aimed to explore the predictive ability of preoperative characteristics in traumatic hip fracture patients as they relate to 30-day postoperative mortality using readily available variables in clinical practice. All adult patients who underwent primary emergency hip fracture surgery in Sweden between 2008 and 2017 were included in the analysis. Associations between the possible predictors and 30-day mortality was performed using a multivariate logistic regression (LR) model; the bidirectional stepwise method was used for variable selection. An LR model and convolutional neural network (CNN) were then fitted for prediction. The relative importance of individual predictors was evaluated using the permutation importance and Gini importance. A total of 134,915 traumatic hip fracture patients were included in the study. The CNN and LR models displayed an acceptable predictive ability for predicting 30-day postoperative mortality using a test dataset, displaying an area under the ROC curve (AUC) of as high as 0.76. The variables with the highest importance in prediction were age, sex, hypertension, dementia, American Society of Anesthesiologists (ASA) classification, and the Revised Cardiac Risk Index (RCRI). Both the CNN and LR models achieved an acceptable performance in identifying patients at risk of mortality 30 days after hip fracture surgery. The most important variables for prediction, based on the variables used in the current study are age, hypertension, dementia, sex, ASA classification, and RCRI.

Background: The incidence of severe respiratory complications in patients with pelvis fractures needing intensive care have not previously been studied. Therefore, the aims of this registry study were to 1) determine the number of ICU patients with pelvis fractures who had severe respiratory complications 2) whether the surgical intervention in these patients is associated with the pulmonary condition and 3) whether there is an association between lung complications and mortality. We hypothesized that acute hypoxic failure (AHF) and acute respiratory distress syndrome (ARDS) 1) are common in ICU treated patients with pelvis fractures, 2) are not related to the reconstructive surgery, or to 3) to mortality.

Methods: All patients in the database cohort (n = 112), scheduled for surgical stabilization of pelvis ring and/or acetabulum fractures, admitted to the general ICU at Uppsala University Hospital between 2007 and 2014 for intensive care were included.

Results: The incidence of AHF/ARDS was 67 % (75/112 patients), i.e., the percentage of patients that at any period during the ICU stay fulfilled the AHF/ARDS criteria. The incidence of AHF was 44 % and incidence of ARDS was 23 %. The patients with AHF/ARDS had more lung contusions and pneumonia than the patients without AHF/ARDS. Overall, there were no significant changes in oxygenation variables associated with surgery. However, 23 patients with pre-operative normal lung status developed AHF/ARDS in relation to the surgical procedure, whereas 12 patients with AHF/ARDS normalized their lung condition. The patients who developed AHF/ARDS had a higher incidence of lung contusion (P = 0.04) and the surgical stabilization was performed earlier (5 versus 10 days) in these patients (P = 0.03).

Conclusions: We found that the incidence of respiratory failure in ICU treated patients with pelvis fractures was high, that the procedure around surgical stabilization seems to be associated with a worsening in the respiratory function in patients with lung contusion, and that mortality was low and was probably not related to the respiratory condition.

Objectives: Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.

Methods: The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.

Results: The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.

Conclusions: The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.

Level of evidence: Level III, Prognostic and Epidemiological.

PURPOSE: Among hip fracture patients both dementia and frailty are particularly prevalent. The aim of the current study was to determine if dementia functions as a surrogate for frailty, or if it confers additional information as a comorbidity when predicting postoperative mortality after a hip fracture.

METHODS: All adult patients who suffered a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017 were considered for inclusion. Pathological fractures, non-operatively treated fractures, reoperations, and patients missing data were excluded. Logistic regression (LR) models were fitted, one including and one excluding measurements of frailty, with postoperative mortality as the response variable. The primary outcome of interest was 30-day postoperative mortality. The relative importance for all variables was determined using the permutation importance. New LR models were constructed using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

RESULTS: 121,305 patients were included in the study. Initially, dementia was among the top ten most important variables for predicting 30-day mortality. When measurements of frailty were included, dementia was replaced in relative importance by the ability to walk alone outdoors and institutionalization. There was no significant difference in the predictive ability of the models fitted using the top ten most important variables when comparing those that included [AUC for 30-day mortality (95% CI): 0.82 (0.81-0.82)] and excluded [AUC for 30-day mortality (95% CI): 0.81 (0.80-0.81)] measurements of frailty.

CONCLUSION: Dementia functions as a surrogate for frailty when predicting mortality up to one year after hip fracture surgery. The presence of dementia in a patient without frailty does not appreciably contribute to the prediction of postoperative mortality.

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.

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.

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.

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.

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.

BACKGROUND AND AIMS: Long-term prospective data on patient-reported outcome after surgical treatment of pelvic ring injuries are scarce. This study aimed at describing results at 5 years post-surgery using validated outcome measures.

PATIENTS AND METHODS: Patients admitted for surgical treatment of pelvic ring injuries were prospectively included and asked to report their outcome at 1, 2 and 5 years post-surgery using two patient-reported outcome measures: the generic Short-Form 36 and the condition-specific pelvic discomfort index. Data were evaluated using mixed-effects linear models.

RESULTS: There were 108 patients (68 males and 40 females), mean age 38 years. Injury type according to the AO/OTA-classification was B-type in 68 patients and C-type in 40 patients. No domain of the Short-Form 36 reached norm values at 5 years post-surgery. Females reported a worse outcome than males concerning general health (p < 0.01) at 5 years. Recovery of physical function (p < 0.01), mental health (p = 0.04), and pain (p = 0.01) was observed for males at 5 years compared to earlier assessments, while females on the contrary described more pain at this time-point (p = 0.03). Mean pelvic discomfort index at 5 years was 27, indicating moderate residual pelvic discomfort overall. Males reported less pelvic discomfort than females at 5 years (p = 0.02) and improved when compared to results at 2 years (p = 0.02), while females did not. Influence of age, fracture type, and presence of associated injuries on patient-reported outcome was limited.

CONCLUSION: Surgically treated pelvic ring injuries are associated with long-standing negative effects on patient-reported outcome. Males report a better outcome than females at 5 years post-surgery.

BACKGROUND AND PURPOSE: Evaluation of patient-assessed functional outcome in traumatic conditions has specific challenges. To obtain pre-traumatic data to allow for comparison during follow-up, retrospective assessments are needed. How such data is affected by posttraumatic time-point chosen for evaluation is unknown. The primary purpose of this study was to investigate how the time-point chosen for retrospective assessment of pre-traumatic quality of life (QoL) in patients with surgically treated acetabular fractures and pelvic ring injuries influenced the results. A secondary purpose was to examine the pre-traumatic QoL-profile in patients with these injuries.

PATIENTS AND METHODS: 73 patients were included, where 50 had an acetabular fracture and 23 a pelvic ring injury. Pre-traumatic QoL was evaluated using the generic instruments SF-36 and EQ5D in conjunction with the condition-specific Pelvic Trauma Questionnaire (PTQ). Questionnaires were completed at three time points: 0, 1 and 2 months post-surgery.

RESULTS: Number of responders were 73 patients at 0 months, 61 patients at 1 month and 53 patients at 2 months. 50 patients answered the questionnaires at all three time-points. A trend was observed with all instruments where patients estimated a better pre-traumatic status with narrower distributions when assessment was delayed. At 2 months, scores for 4 out of 8 SF-36 domains where significantly higher compared to 0 months. For EQ5D, EQ VAS improved at 1 and 2 months compared to month 0 results but no other significant differences between time-points were found. Results from the PTQ demonstrated no significant differences over time. Pre-traumatic quality of life was high and for SF-36 comparable to a population norm. A very low level of pre-existing discomfort from the pelvic region was reported through the PTQ.

CONCLUSION: Patients with surgically treated acetabular fractures and pelvic ring injuries estimate a higher pre-traumatic functional status when assessment is carried out at 1 or 2 months post-surgery compared to perioperative measurements. The SF-36 seems to be more sensitive than the EQ5D in this respect. Pre-traumatic QoL in patients with surgically treated acetabular fractures and pelvic ring injuries is generally high and pre-existing discomfort from the pelvic region is uncommon.

INTRODUCTION: Dementia is common in patients with hip fractures and is strongly associated with increased postoperative mortality. The choice of surgical intervention for displaced femoral neck fractures (dFNF) in patients with dementia has been a matter of debate. This study aims to investigate how short- and long-term mortality differs between those who have been operated with hemiarthroplasty or pins/screws.

METHODS: All patients with dementia and dFNF, i.e., Garden III and IV, who underwent primary emergency hip fracture surgery, with either hemiarthroplasty or pins/screws, in Sweden between Jan 1, 2008 and Dec 31, 2017 were eligible for inclusion in the current study. Patients were divided into two groups based on the surgical intervention: hemiarthroplasty and pins/screws. The primary outcome of interest was 30-day postoperative mortality, and the secondary outcome was 1-year postoperative mortality. Poisson and Cox regression analyses were performed both before and after propensity score matching.

RESULTS: A total of 9394 cases met the inclusion criteria; 84% received hemiarthroplasty and 16% received pins/screws. In the unmatched analysis, the adjusted incidence rate ratio (IRR) for 30-day postoperative mortality was not affected by the chosen surgical method (adj. IRR 0.96, CI 95% 0.83-1.12, p = 0.629). After propensity score matching, similar results were observed with no difference in 30-day postoperative mortality (adj. IRR 0.89, CI 95% 0.74-1.09, p = 0.286). There was a statistically significant decrease in the risk of 1-year postoperative mortality in the hemiarthroplasty group compared to the pins/screws group, both before and after propensity score matching.

CONCLUSION: This study could not demonstrate any difference in 30-day mortality in patients with dementia and dFNFs when comparing hemiarthroplasty with pins/screws. Patients that received hemiarthroplasties did, however, have a lower risk of 1-year postoperative mortality.

PURPOSE: Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population.

METHODS: All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality.

RESULTS: 134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60-1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99-11.07), p < 0.001].

CONCLUSIONS: Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

PURPOSE: Dementia, present in 20% of hip fracture patients, is associated with an almost threefold increase in postoperative mortality risk. These patients have a substantially higher incidence of cardiovascular, respiratory, and cerebrovascular mortality after hip fracture surgery compared to patients without dementia. This study aimed to investigate the association between beta-blocker therapy and postoperative mortality in patients with dementia undergoing hip fracture surgery.

METHODS: This nationwide study included all patients in Sweden with the diagnosis of dementia who underwent emergency surgery for a hip fracture between January 2008 and December 2017. Cases where the hip fracture was pathological or conservatively managed were not included. Poisson regression analysis with robust standard errors was performed while controlling for confounders to determine the relationship between beta-blocker therapy and all-cause, as well as cause-specific, postoperative mortality.

RESULTS: A total of 26,549 patients met the study inclusion criteria, of whom 8258 (31%) had ongoing beta-blocker therapy at time of admission. After adjusting for clinically relevant variables, the incidence of postoperative mortality in patients receiving beta-blocker therapy was decreased by 50% at 30 days [adj. IRR (95% CI) 0.50 (0.45-0.54), p < 0.001] and 34% at 90 days [adj. IRR (95% CI) 0.66 (0.62-0.70), p < 0.001]. Cause-specific mortality analysis demonstrated a significant reduction in the incidence of postoperative cardiovascular, respiratory, and cerebrovascular death within 30 and 90 days postoperatively.

CONCLUSION: Beta-blocker therapy is associated with decreased postoperative mortality in hip fracture patients with dementia up to 90 days after surgery. This finding warrants further investigation.

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.

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.

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.

Hip dysplasia in young adults is underdiagnosed and can cause pain and discomfort. Progression to osteoarthritis (OA) is common, necessitating total hip arthroplasty at an early age. When discovered early, symptomatic patients can be offered physiotherapy and/or hip-preserving surgery to alleviate pain and decrease the risk of early OA. A pilot project to screen radiograms for hip dysplasia was started across the Swedish region of orebro Lan in January 2019, comparing the incidence of dysplasia before and after initiation of the screening program. All elective conventional radiograms of the hip (age 12-44 years), requested by primary care physicians, were analyzed by consultant radiologists according to a pre-established algorithm to identify hip abnormalities. If the hip radiograms showed dysplastic changes, or other pathological signs, the radiologist advised referral to a specialized Youth Hip Clinic for further work-up and treatment. A total of 1056 radiograms were requested by clinicians during the study periods (601 and 455 during 2018 and 2020, respectively). A total of 457 trauma-related cases were excluded, resulting in 599 available for analysis (348 and 251 during 2018 and 2020, respectively). During 2018, 17 patients (4.9%) received the radiologic diagnosis of dysplasia, compared with 44 patients (17.5%) during 2020 (P < 0. 001). A three-fold increase of patients diagnosed with hip dysplasia was detected as a result of the implementation of the screening program. The advantage of screening is early referral to an orthopedic department for evaluation and consideration for physiotherapy and/or surgical intervention.