To Örebro University

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

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

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

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

PURPOSE: Despite improvements in total wrist arthroplasty (TWA) designs, periprosthetic osteolysis, and implant loosening are challenging issues. A new TWA implant design with a tantalum coating has been proposed to address these issues. This study reports the results of a pilot study of 20 cases operated on with the new TWA design.

METHODS: Of the 20 cases, 14 were primary TWAs and 6 were revision TWAs. Patients were assessed using visual analog scale pain scores, wrist range of motion, hand grip strength, and patient-reported outcome measures (PROMs) before surgery and 1, 2, and no later than 8 years after surgery. Radiographic examination was performed to assess any loosening of the TWA.

RESULTS: Of the 20 patients, 19, including 12 men and 7 women, came for postoperative follow-up at a mean of 6.5 years (5-8 years). Two reoperations were performed in two patients in the primary TWA group, compared with seven reoperations in six patients in the revision TWA group. Three of the reoperations were revision surgeries with conversion to radiocarpal arthrodesis, one in the primary TWA group and two in the revision TWA group. All three radiocarpal arthrodeses healed radiographically, but one of the patients underwent implant removal because of prominent hardware. Another patient in the revision TWA group had loosening of the articular head at the snap-fit mechanism and was offered revision surgery but declined further operative treatment. The radiographic examinations did not indicate implant loosening at the last follow-up. Range of motion, PROMs, and visual analog scale pain scores all improved at final follow-up.

CONCLUSIONS: The new TWA design gave improved PROMs, and the frequency of implant loosening was low. The number of revisions remains a concern, but most followed the revision TWA.

Type of study/level of evidence: Therapeutic IV.

BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR). METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality.

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

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

BACKGROUND AND PURPOSE: Fracture-related infections (FRIs) after osteosynthesis for hip fractures have not been thoroughly investigated. Our primary aim was to assess the association between FRIs and mortality after osteosynthesis for hip fracture. Secondary aims were to investigate the incidence, microbiology, and general epidemiological aspects of these FRIs.

METHODS: This retrospective single-center study included 1,455 patients > 18 years old with non-pathological hip fractures treated with osteosynthesis between 2015 and 2019. Medical records were reviewed and FRIs were diagnosed based on current consensus criteria. The follow-up period was 2 years. Mortality was estimated using Kaplan-Meier survival analysis. Cox regression analyses were performed to investigate the potential association between FRIs, as a time-dependent variable, and increased mortality.

RESULTS: The median age for the entire cohort was 83 (interquartile range 75-89) years and 69% were females. At the 2-year follow-up mark, the crude mortality rate was 33% in the non-FRI group and 69% (11 of 16 patients) in the FRI group. Cox regression analysis assessing mortality risk revealed a hazard ratio of 3.5 (95% confidence interval [CI] 1.9-6.4) when adjusted for confounders. The incidence of FRI was 1.1% (16 of 1,455 patients). Staphylococcus aureus was the most common pathogen. Most FRI patients (94%) required at least 1 revision and 56% underwent ≥ 2 revision.

CONCLUSION: We found an association between FRIs after hip fracture osteosynthesis and increased mortality, underscoring the critical need for FRI prevention measures in this frail patient group. The incidence and microbiological findings were consistent with previous studies.

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.

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.

Purpose: To assess long-term implant survival in total wrist arthroplasty (TWA), comparing 4 different implants.

Methods: In a prospective cohort of 124 patients, 136 TWAs were evaluated 5 years and 10 years after surgery. The TWAs were implanted between 2005 and 2009. The primary outcome was implant survival. Survival analysis was performed with revision and radiographic loosening as the final end point. Revision was defined as exchange of whole or parts of the prosthesis. Implant loosening was assessed using radiographic examination at the 5-year and 10-year follow-up. Secondary outcome measures included wrist range of motion, hand grip strength, visual analog scale (VAS) pain scores, and patient-related outcome measures, including Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Canadian Occupational Performance Measure (COPM).

Results: Total cumulative implant survival was 92% with revision as the primary end point. When including a nonrevised radiographic loose implant as a failure, total implant survival was 75%. Radiographic loosening differed significantly between the implants with a range in frequency from 0% to 37.5%. At the 10-year follow-up, assessing the nonrevised TWAs, range of motion was preserved compared with preoperative values. Significant improvement was recorded for hand grip strength, VAS pain scores, and patient-related outcome measures at the 10-year follow-up compared with preovperative values.

Conclusions: High 10-year implant survival was found when defining the primary end point as revision of any cause. When including radiographic loosening of the implant in the survival analysis, implant survival was considerably lower. However, radiographic loosening does not seem to correlate with changes in secondary outcome measures, questioning the need for revision surgery in these cases.

Aim: To study implant survival and implant loosening following primary total wrist arthroplasty (TWA) using four different implants. To report outcome following wrist revision arthroplasty. To evaluate a new radial wrist hemi arthroplasty (RWHA) design clinically and biomechanically.

Method: The studies included 136 primary TWAs and 16 revision TWAs, both studies with prospectively collected data. Six fresh frozen cadaveric wrist specimen were used for biomechanical analysis. The RHWA was evaluated clinically in a pilot series of 20 cases.

Results: Total implant survival was 92% but with high frequency of implant loosening of surviving Re-Motion implants. None of the surviving Maestro implants were considered radiographically loose. Implant survival following revision arthroplasty was 75%, considerably lower than following primary TWAs. However, none of the patients with surviving revision implants had pain at rest and little or no pain in activity. The surgical procedure and placement of the RHWA was feasible. Overall, the kinematic and functional changes appeared acceptable compared to the native wrist. None of the patients underwent revision following RHWA but reoperation was performed in 7 patients on the indication of persistent pain. However, patients reported relief of pain and improvement of patient-reported outcome measures.

Conclusion: High long-term implant survival and no signs of radiographic loosening was found for the Maestro implant. However, the Maestro implant is no longer available on the market and we believe there is a need for new TWA designs. Revision arthroplasty is a valid option in the management of failed TWA. However, implant survival is lower than for primary TWAs and as many as 25% require additional surgery. Promising results were found using the new RHWA design but the implant needs modification before further testing.

Purpose: A biomechanical functional assessment was performed on a newly designed wrist hemiarthroplasty implant with aimed to identifying differences between the native wrist and wrist following the hemiarthroplasty procedure with (Hemi+PRC) and without a proximal row carpectomy (Hemi).

Methods: Six cadaveric wrists were mounted on a custom testing fixture and underwent a series of functional tests to investigate differences in range of motion, muscles moment arms, and axis of rotation between the intact and post-operative wrists. The tested movements included manually-driven flexion-extension, radial-ulnar deviation, dart throwers motion, and circumduction.

Results: The only significant change in range of motion was a decrease in flexion between the intact (77.75±14.40°) and both the Hemi (65.97±17.72°) and Hemi+PRC (60.08±17.18°) conditions. Minor differences in the mean position and variability of the axis of rotation's piercing point were identified. A statistically significant decrease in the flexion moment arm of the flexor carpi radialis was identified between the intact (16.1±2.6mm) and Hemi+PRC (14.0±3.4mm) conditions. Statistically significant decreases were also identified in the radial deviation moment arms of the extensor carpi radialis brevis' between the intact (15.3±7.8mm) and Hemi+PRC (7.3±12.5mm) conditions and the flexor carpi radialis' between the intact (15.3±3.2mm) and Hemi (12.0±5.7mm) conditions as well as in the ulnar deviation moment arm of the extensor carpi ulnaris between the intact (34.9±11.3mm) and Hemi (13.2±21.9mm) conditions.

Conclusions: While some statistically significant functional changes were identified between the native and hemiarthroplasty wrist, the findings suggest that post-operative function is equally acceptable in hemiarthroplasty with and without resection of the proximal carpal row. © 2018 World Scientific Publishing Company.

PURPOSE: Management of failed total wrist arthroplasty (TWA) can be challenging; surgical treatment options include salvage arthrodesis, revision arthroplasty, and resection arthroplasty. There are few studies regarding salvage arthrodesis, and revision arthroplasty has been infrequently investigated. The aim of the study was to report the outcome after revision arthroplasty of the wrist.

METHODS: A retrospective cohort of 16 revision TWAs was evaluated between 2003 and 2016. Data were collected before surgery and 1 and 5 years after surgery. The indication for revision arthroplasty was failed TWA. The primary end point was implant survival. Secondary outcome measures included visual analog scale (VAS) pain scores, range of motion, handgrip strength, and functional scoring with the Canadian Occupational Performance Measure (COPM), Patient-Rated Wrist Evaluation (PRWE), and Disabilities of the Arm, Shoulder, and Hand (DASH).

RESULTS: Mean follow-up was 6.6 years. Synthetic bone graft was used in 9 cases, allograft corticocancellous bone graft in 1 case, and cement in 6 cases. Of the 16 revision TWAs, 4 were re-revised, 1 because of infection, and 3 cases underwent total wrist arthrodesis. In the non-re-revised cases, range of motion and grip strength was preserved compared with preoperative results. The VAS pain score in activity improved, but not significantly, at 1 (median, 1; range, 0-4.5) and 5 years after surgery (median, 0) compared with before surgery (median, 5). The COPM performance and satisfaction as well as PRWE scores improved significantly at 1 year (median COPM performance, 4.8; COPM satisfaction, 5.6; and PRWE, 24) and improved, but not significantly, at the 5-year follow (median COPM performance, 4.8; COPM satisfaction, 5.0; and PRWE, 37) in the non-re-revised cases.

CONCLUSIONS: Revision arthroplasty of the wrist is a valid motion-preserving option to wrist arthrodesis in the management of failed TWA. However, the outcome is uncertain and as many as 25% require additional surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.