To Örebro University

INTRODUCTION: Distal radial fractures are the most common fractures in adults. Maltreatment of distal radial fractures can result in pain and disability. The most common complications and maltreatment after distal radial fractures are malunion, tendon injury, infection and nerve injury. The Swedish Patient Insurance Company (LÖF) indemnifies approximately 90% of all healthcare providers in Sweden. The aim of this study was to assess maltreated distal radius fractures using data from the LÖF-register in combination with data from the Swedish Fracture Register.

METHOD: All insurance claims relating to patient-reported maltreatment of distal radial fractures in adults in Sweden, as well as data from the Swedish Fracture Register regarding fracture type and patient-reported outcome measures during the period 2011-2021 were analysed.

RESULTS: Of the total of 1393 claims relating to distal radial fractures during the study period, the frequency of reported maltreatment claims was 1.4%. Eighty-two per cent of the claimants were female and the median age was 60 years. Malunion was the most common overall complication, carpal tunnel syndrome was the most common nerve-related complication and extensor pollicis longus tendon rupture following anterior plating was the most common tendon-related complication. Sixty-four per cent of the claims were accepted and reimbursed. The total direct cost for maltreated distal radial fractures was €4,980,000.

CONCLUSION: Reducing the number of symptomatic malunions, ensuring correct anterior plate placement and identifying other critical steps in treatment would likely improve patient safety and decrease the additional financial burden for the society.

LEVEL OF EVIDENCE: IV.

BACKGROUND: Distal radius fracture (DRF) is the most common of fractures, accounting for 18% of all fractures. The ability to return to work is an important outcome for both society and the individual, but there is a large variation among patients in how much time off work is required. The choice of treatment is likely an important factor.

METHODS: This study was a secondary analysis of an earlier published randomised clinical trial comparing volar locking plate fixation with combined dorsal and volar plate fixation of AO type C DRF. In the present study, we examined the the duration of sick leave among patients who were in the workforce at the time of fracture.

RESULTS: There were 84 cases included in this analysis.Combined plating was associated with a significantly longer time to return to work following a type C DRF, in comparison to treatment with a volar locking plate. The crude difference was 0.67 months (p = 0.33; 95% CI: 0.85-1,26 months), and 0.65 months (p = 0.15; 95% CI: 0.13-1.17) when adjusting for differences in manual labour indicating a statistically significant difference time until return to work.

CONCLUSIONS: Sick leave is an important contributor to total costs in patients with DRF, and more invasive treatments like combined plating are associated with longer sick leave. Our results indicate a longer time until return to work in the combined plating group, possibly due to more extensive soft tissue dissection. We recommend a restrictive use of combined plating.

TRIAL REGISTRATION: The study was registered in the Swedish research database FoU in Sweden (registration number: 274674) on the 4th of August 2020.

BACKGROUND: No international consensus regarding optimal non-surgical or surgical treatment of metacarpal fractures exists. Surgical outcome using patient-reported outcome measurements (PROMs) from national registers with large surgically treated population have rarely been reported. We present demographics and patient-reported outcomes in relation to fixation methods for surgically treated metacarpal fractures, using data from the Swedish National Quality Registry for Hand Surgery (HAKIR).

METHODS: In a retrospective analysis of a prospective collected dataset, patients aged ≥ 18 years with surgically treated metacarpal fractures registered in HAKIR during 2010-2022 were included (fracture types currently unknown), excluding reoperations and fractures associated with other injuries. PROMs (QuickDASH and HQ-8 routinely used) were collected at 3 and 12 months postoperatively. Data were compared with Chi-squared, Mann-Whitney, Kruskal-Wallis or Wilcoxon signed-rank tests and PROM changes over time were expressed as effect size.

RESULTS: In 3,286 analyzed cases, male patients were more frequently treated than females. Males were significantly younger than females (p < 0.001). Outcome, measured with QuickDASH, showed significant improvement from 3 (median: 15.9, interquartile range [IQR]: 6.8-31.8) to 12 months (median: 8.0, IQR: 2.3-20.5) (p < 0.001) with no significant differences between fractures in thumb, fingers, and multiple fractures at 12 months. QuickDASH scores at 12 months showed no significant differences between fixation methods. Outcome between open and closed fractures did not differ. K-wire/cerclage (61%) was most frequently used fixation method (plate fixation (16%), screw fixation (11%) with a significant variation between hospitals, e.g., variation K-wire/cerclage use: 29%-80% (p < 0.001). At 12 months, only HQ-8 item weakness showed significantly better outcome for screws without plating compared to K-wire/cerclage (p = 0.048).

CONCLUSION: Based on national register data from a larger surgically treated population, good patient-reported outcome is expected one year after surgery for isolated metacarpal fractures with K-wire/cerclage being most common surgical fixation method. Despite notable national variation in fixation methods, likely influenced by currently unknown fracture types and possibly other confounding factors, no overall differences in outcome based on the PROM QuickDASH were observed. However, less weakness was noted 12 months postoperatively following screw fixation.

BACKGROUND: In distal radius fracture (DRF) surgery with volar locking plates, the flexor carpi radialis approach is commonly used. However, the volar central approach (VCA), between the median nerve and the finger flexors, may improve visualization of the volar ulnar corner. A similar approach has been linked with a higher risk of iatrogenic median neuropathy. This study evaluated the risk of median neuropathy after operative treatment using the VCA.

METHODS: Thirty-eight patients with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C DRF were assessed prospectively with sensory nerve conduction studies preoperatively and at 6 weeks, 3 months, and 12 months postoperatively.

RESULTS: At 6 weeks, 30 of the 38 patients exhibited median neuropathy, decreasing to 12 of the 35 at 12 months. Subjective sensory deficit was reported by 12 of the 38 patients at 6 weeks and 8 of the 37 at 12 months. Patients with median neuropathy (MN) had significantly higher frequency of subjective sensory deficit of the median nerve 12 months postoperatively, but did not have significantly worse patient-reported outcome.

CONCLUSIONS: Our results suggest that the VCA should be reserved for cases needing optimal exposure of the volar ulnar corner.

PURPOSE: The purpose of this study was to compare the clinical and radiographic outcomes 5 years after randomization to volar plating or combined plating for surgical treatment of an AO (Arbeitsgemeinschaft für Osteosynthesefragen) type C distal radius fracture (DRF).

METHODS: A total of 150 patients were previously randomized to a volar locking plate or combined plating for treatment of an AO type C DRF with strict inclusion and exclusion criteria. All participating patients were invited for a 5-year postoperative follow-up. Radiographs, pain (visual analog scale), grip strength, and range of motion were documented, along with the Patient-Rated Wrist Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, and EuroQol 5-Dimension questionnaires. Arthritis in the radiocarpal and distal radioulnar joint was graded on radiographs by a senior radiologist according to the Knirk and Jupiter classification.

RESULTS: There were 135 patients (66 in the volar plate group and 69 in the combined plating group), corresponding to a 90% follow-up rate. Median age at follow-up was 67 years (interquartile range 57-75). There was no difference in radiographic arthritis between the two groups. The volar plate group had significantly better outcomes in flexion, extension, radial deviation, and Patient-Rated Wrist Evaluation (P < .05). There were no significant between-group differences in the Quick Disabilities of the Arm, Shoulder, and Hand, EuroQol 5-Dimension index, or EuroQol Visual Analog Scale (P > 05). Hardware removal was significantly more common in the combined plating group (64%) than in the volar plate group (30%) (P < .001).

CONCLUSIONS: Among surgically treated patients with AO type C DRF, those operated with volar plating had better clinical outcomes 5 years after surgery compared to those treated with combined plating, but the minimal clinically important difference was not reached. These findings support volar plating as the preferred method for AO type C DRFs.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Background: Primary total hip arthroplasty and total knee arthroplasty are common surgical procedures that require effective perioperative care to ensure early mobilisation, reduced complications, and shortened hospital stay. Effect-site target-controlled infusion (TCI) combined with SmartPilot View (SPV) is a novel approach to total intravenous anaesthesia that may improve anaesthetic precision and reduce postoperative side effects. However, it has not been thoroughly evaluated in joint arthroplasty. The aim of this study was to evaluate the early anaesthetic outcomes in hip and knee arthroplasty patients following the implementation of effect-site TCI and SPV.

Methods: We conducted a retrospective cohort study including 2316 procedures (2210 patients) at & Ouml;rebro University Hospital, Lindesberg, Sweden, between 2018 and 2023. Two groups were compared: pre-implementation (2018-2019, n = 1258) using plasma-targeted TCI without SPV, and post-implementation (2022-2023, n = 1058) using effect-site TCI with SPV. Patients from 2020 to 2021 were excluded due to the COVID-19 pandemic and the overlap of methods during implementation. Data were extracted from the Swedish Perioperative Register. The primary outcome was the incidence of postoperative nausea and vomiting (PONV). Secondary outcomes included length of stay in the post-anaesthesia care unit (phase II), postoperative pain, and surgical duration.

Results: PONV incidence decreased significantly from 8.4% to 3.0% after implementation (p < 0.001; adjusted OR: 0.36, 95% CI: 0.23-0.55). Median post-anaesthesia care unit stay decreased by 70 min (95% CI: 61-78 min; p < 0.001). Postoperative pain scores were slightly lower in the post-implementation group (median numeric rating scale 7 vs. 5; p < 0.001). Surgical duration increased marginally (84 vs. 87 min; p = 0.003).

Conclusions: Implementation of effect-site TCI and SPV in hip and knee arthroplasty was associated with significantly reduced PONV and shorter post-anaesthesia care unit stay, suggesting improved early postoperative recovery.

Clinical trial number: Not applicable.

This study aimed to investigate the association of socioeconomic factors, country of birth and comorbidities with poor patient-reported outcome 1 year after a distal radial fracture. The patient population was obtained from the Swedish Fracture Register. In the study, 17,468 patients 18 years or older were included. Poor outcome was the dependent variable in a multivariate logistic regression analysis. The factors with the strongest association with poor outcome were country of birth outside the European Union (odds ratio (OR) = 2.28; 95% CI = 1.91-2.73), high-energy trauma mechanism (OR = 1.76; 95% CI = 1.46-2.12), a history of anxiety or depression (OR = 1.46; 95% CI = 1.26-1.70), and a Charlson comorbidity index ≥3 (OR = 1.51; 95% CI = 1.17-1.94). Alleviating the effects of these factors could potentially decrease the proportion of patients with a disability after a distal radial fracture.Level of evidence: III.

BACKGROUND: Arthrodesis of finger joints is often the last line of treatment of severe pain due to osteoarthritis, rheumatoid arthritis, or mallet finger. At the Department of Orthopedic and Hand Surgery, Örebro University Hospital (ÖUH) in Sweden, the Kirschner-wire technique was standard until 2020, when the headless compression screw technique was introduced as a complement. There is no consensus on which method is superior. The purpose of this study was to examine the outcomes and complications associated with distal interphalangeal (DIP) joint and thumb interphalangeal (IP) joint arthrodesis, and to see whether these correlated with patient-dependent and treatment-related factors.

METHODS: In a retrospective cohort study, we evaluated a total of 149 consecutive arthrodeses (118 DIP joint and 31 thumb IP joint) performed between 2012 and 2022. The primary outcome was risk factors for complications after arthrodesis.

RESULTS: Osteoarthritis was the most common indication (56%) for arthrodesis. The majority of the patients were females (74%), and the median age was 62 (range 18-86). The complication frequency was 35%, with infection being the most common (25%). Time to completed follow up was < 12 weeks in the majority of the cases (58%). There were no significant differences in complication rate between the 136 joints operated using Kirschner wire and the 13 joints operated using headless compression screws. There was no significant increased risk of complications among smokers or patients with rheumatoid arthritis. Diabetes and surgeon experience had a significant influence on the risk of complication (p = 0.036 and p = 0.006, respectively).

CONCLUSIONS: Osteoarthritis was the most common indication for arthrodesis and postoperative complications occurred at a rate similar to that reported in the existing literature. Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in these DIP/thumb IP joint arthrodeses. However, there was no significant difference between the two techniques (Kirschner wire and headless compression screws) regarding complications. Further studies are needed in order to determine the optimal type of operation and choice of implant.

TRIAL REGISTRATION: Researchweb CRIS #280,998, 26th of July 2023.

BACKGROUND: Adequate postoperative pain treatment is important for quality of life, patient satisfaction, rehabilitation, function, and total opioid consumption, and might lower both the risk of chronic postoperative pain and the costs for society. Prolonged opioid consumption is a well-known risk factor for addiction. Previous studies in upper extremity surgery have shown that total opioid consumption is a third of the amount prescribed, which can be explained by package size. The aim of this study was to examine whether implementation of prepacked takehome analgesia bags reduced the quantity of prescribed and dispensed opioids.

MATERIAL AND METHODS: We introduced prepacked take-home analgesia bags for postoperative pain treatment in outpatient surgery. The bags came in two sizes, each containing paracetamol, etoricoxib, and oxycodone. The first 147 patients who received the prepacked analgesia bags were included in the study, and received a questionnaire one month after surgery covering self-assessed pain (visual analog scale of 0-10) and satisfaction (0-5), as well as opioid consumption. Prescription data after introducing the analgesia bags were compared with data before the bags were introduced.

RESULTS: Of the 147 patients included in the study, 58 responded. Compared to standard prescription (small bag group: 14 oxycodone immediate release capsules (5 mg), large bag group: additional 28 oxycodone extended release tablets (5 mg), based on the smallest available package), the patients in the small analgesia bag group received 50% less oxycodone and 67% less for the large bag group. Patients with small bags consumed a median of 0.0 mg oxycodone and those with large bags consumed a median of 25.0 mg oxycodone. The median satisfaction was 5.0 (range: 2-5) and the median pain score was acceptable at the first postoperative day. Prescription data showed a significant reduction of 60.0% in the total amount of prescribed opioids after the introduction of prepacked analgesia bags.

CONCLUSIONS: The introduction of prepacked analgesia bags dramatically reduced the quantity of opioids prescribed after outpatient hand surgery. Patient satisfaction was high and the postoperative pain level was acceptable.

PURPOSE: The purpose of this study was to assess the long-term clinical, subjective, and radiographic results of pyrocarbon hemiarthroplasty for proximal interphalangeal joint (PIPJ) arthritis at a single institution.

METHODS: Patients treated with a pyrolytic carbon hemiarthroplasty between 2005 and 2015 were contacted for a clinical follow-up visit. Patients were assessed before surgery, one year after surgery, and again after a mean of 11 years (range: 6-16 years). Objective outcomes were assessed with grip strength, pinch strength, and range of motion (ROM). Subjective outcomes were assessed by the Disabilities of the Arm, Shoulder, and Hand score, Canadian Occupational Performance Measure (performance and satisfaction), and Visual Analog Scale pain scores at rest and during activity. Radiographic assessments were completed according to Sweets and Stern as modified by Wagner et al.

RESULTS: A total of 68 fingers in 52 patients underwent PIPJ hemiarthroplasty. Thirty-six arthroplasties in 29 patients were available for the long-term follow-up, five patients had died, and the remaining cases were contacted by phone. Three cases were lost to follow-up. Preoperative diagnoses included 41 fingers with osteoarthritis or posttraumatic arthritis, and 27 fingers with inflammatory arthritis. Eight cases had undergone revision at the time of follow-up, and the 10-year implant survival was 72%. The revisions were performed after a mean of two years after surgery. Three patients had undergone soft-tissue procedures. Visual Analog Scale pain scores, Disabilities of the Arm, Shoulder, and Hand scores, and Canadian Occupational Performance Measure scores improved significantly compared with that before surgery. Grip strength and pinch grip remained unchanged. However, PIPJ ROM deteriorated significantly one year after surgery, when compared with that before surgery.

CONCLUSIONS: Pyrocarbon hemiarthroplasty of the PIPJ has an acceptable long-term implant survival, and the significant improvement in pain scores and patient-reported outcomes is maintained over time. Pyrocarbon hemiarthroplasty could be a viable option in the management of PIPJ arthritis. Patients should be advised that PIPJ ROM deteriorates over time.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.