To assess the role of four biomarkers of neuroendocrine activation and endothelial dysfunction in the longitudinal prediction of fragility fractures.
We analysed a population-based prospective cohort of 5415 community-dwelling individuals (mean age, 68.9±6.2 years) enrolled in the Malmö Preventive Project followed during 8.1±2.9 years, and investigated the longitudinal association between C-terminal pro-arginine vasopressin (CT-proAVP), C-terminal endothelin-1 precursor fragment (CT-proET-1), the mid-regional fragments of pro-adrenomedullin (MR-proADM) and pro-atrial natriuretic peptide (MR-proANP), and incident vertebral, pelvic and extremity fractures.
Overall, 1030 (19.0%) individuals suffered vertebral, pelvic or extremity fracture. They were older (70.7±5.8 vs 68.4±6.3 years), more likely women (46.9% vs 26.3%), had lower body mass index and diastolic blood pressure, were more often on antihypertensive treatment (44.1% vs 38.4%) and had more frequently history of fracture (16.3% vs 8.1%). Higher levels of MR-proADM (adjusted HR (aHR) per 1 SD: 1.51, 95% CI 1.01 to 2.28, p
Treatment of displaced femoral neck fractures in Sweden has shifted towards more arthroplasties, especially hemiarthroplasties. We describe the hemiarthroplasty population in Sweden 2005 through 2009.
Since 2005, the Swedish Hip Arthroplasty Register has registered hemiarthroplasties on a national basis. We assessed hemiarthroplasty procedures in the Register 2005-2009 regarding patient details, implants, and surgical techniques. Completeness of recordings was calculated compared to the Swedish National Patient Register.
Completeness increased from 89% to 96% during the study period. 21,346 hemiarthroplasty procedures were assessed. The relative number of patients with femoral neck fracture as diagnosis increased from 91% to 94%; the proportion of men increased from 27% to 30%. The median age increased from 83 to 84 years in men and from 84 to 85 years in women. Patients classified as having evident cognitive impairment increased from 19% to 22%. More men than women were ASA 4. The proportion of monoblock-type implants (Austin-Moore and Thompson) decreased from 18% to 0.9%. Modular implants increased generally, but in 2009 bipolar implants decreased in favor of unipolar implants. Lubinus and Exeter stems, and Mega Caput and Vario Cup implant heads were most common. The use of uncemented implants decreased from 10% to 3%. Use of the anterolateral approach increased from 47% to 56%.
Important changes in surgical technique and implant choice occurred during the observation period. We interpret these changes as being reflections of the continuing effort by Swedish orthopedic surgeons to improve the quality of treatment, because the changes are consistent with recent findings in the Swedish Hip Arthroplasty Register and in other scientific studies.
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Background and purpose - In-hospital death following total hip arthroplasty (THA) is related to comorbidity. The long-term effect of comorbidity on all-cause mortality is, however, unknown for this group of patients and it was investigated in this study. Patients and methods - We used data from the Swedish Hip Arthroplasty Register, linked to the National Patient Register from the National Board of Health and Welfare, for patients operated on with THA in 1999-2012. We identified 120,836 THAs that could be included in the study. We evaluated the predictive power of the Charlson and Elixhauser comorbidity indices on mortality, using concordance indices calculated after 5, 8, and 14 years after THA. Results - All comorbidity indices performed poorly as predictors, in fact worse than a base model with age and sex only. Elixhauser was, however, the least bad choice and it predicted mortality with concordance indices 0.59, 0.58, and 0.56 for 5, 8, and 14 years after THA. Interpretation - Comorbidity indices are poor predictors of long-term mortality after THA.
We included in a prospective, randomized study 68 patients aged 70 years or older, with displaced cervical hip fractures. The patients were randomized to internal fixation with hook-pins (36) or primary arthroplasty (32) (total or hemiarthroplasty due to their prefracture status) and followed for 2 years. Patients with rheumatoid arthritis, mental confusion and/or residence in an institution were excluded. The postoperative stay in hospital, rehabilitation wards or nursing homes were recorded as well as complications and the costs of surgery. The aim of this study was to compare the accumulated costs of each method, during the first 2 years after the fracture. In the internal fixation group, 15/36 were considered failures, as compared to 1/32 in the arthroplasty group. As regards primary treatment of the fracture, the durations of surgery and hospital stay were shorter after internal fixation, but the total need for hospitalization/institutionalization was somewhat longer in these patients. The mean 2-year cost for a patient with internal fixation was USD 21,000 and of one with primary arthroplasty USD 15,000. We conclude that primary arthroplasty is a cost-efficient treatment. Considering the very much higher failure rate after internal fixation--leading to increased suffering for these patients--primary arthroplasty stands out as the best method for displaced fractures of the femoral neck.
National registration of hemiarthroplasties after hip fractures has been established in both Norway and Sweden. We aimed to investigate differences in demographics, choice of implant selection, surgical approaches, and reoperations between the Norwegian Hip Fracture Register (NHFR) and the Swedish Hip Arthroplasty Register (SHAR). As part of the Nordic Arthroplasty Register Association (NARA) project a common hemiarthroplasty dataset has been established. 36,989 primary hemiarthroplasties (HAs) for acute hip fractures reported to NHFR (n = 12,761) and SHAR (n = 24,228) for the period 2005-2010 were included. Cemented prostheses were used in 78% of the operations in Norway and in 95% of the patients in Sweden. In Norway HAs almost exclusively had bipolar design (98%), whereas in Sweden HAs with unipolar design were used in 42% of the cases. Monoblock (non-modular) prostheses were uncommon, but still more frequently used in Sweden than in Norway (6.9% and 2.1% respectively). The lateral approach was more common in Norway (83%) than in Sweden (52%), where the posterior approach was used in 42% of the cases. The five-year survival of all HAs was 95.5% (95% CI: 94.8-96.2) in Norway and 94.8% (95% CI: 94.4-95.3) in Sweden. We concluded that surprisingly large differences between the two countries in demographics, implant design, and surgical technique had been revealed. This common dataset enables further investigations of the impact of these differences on revision rates and mortality.
Sweden offers a unique opportunity to researchers to construct comprehensive databases that encompass a wide variety of healthcare related data. Statistics Sweden and the National Board of Health and Welfare collect individual level data for all Swedish residents that ranges from medical diagnoses to socioeconomic information. In addition to the information collected by governmental agencies the medical profession has initiated nationwide Quality Registers that collect data on specific diagnoses and interventions. The Quality Registers analyze activity within healthcare institutions, with the aims of improving clinical care and fostering clinical research.
The Swedish Hip Arthroplasty Register (SHAR) has been collecting data since 1979. Joint replacement in general and hip replacement in particular is considered a success story with low mortality and complication rate. It is credited to the pioneering work of the SHAR that the revision rate following hip replacement surgery in Sweden is amongst the lowest in the world. This has been accomplished by the diligent follow-up of patients with feedback of outcomes to the providers of the healthcare along with post market surveillance of individual implant performance. During its existence SHAR has experienced a constant organic growth. One major development was the introduction of the Patient Reported Outcome Measures program, giving a voice to the patients in healthcare performance evaluation. The next aim for SHAR is to integrate patients' wishes and expectations with the surgeons' expertise in the form of a Shared Decision-Making (SDM) instrument. The first step in building such an instrument is to assemble the necessary data. This involves linking the SHARs database with the two aforementioned governmental agencies. The linkage is done by the 10-digit personal identity number assigned at birth (or immigration) for every Swedish resident. The anonymized data is stored on encrypted serves and can only be accessed after double identification.
This data will serve as starting point for several research projects and clinical improvement work.
The surgical methods for treatment of femoral neck fractures and trochanteric hip fractures vary. We describe the changes in Sweden over the period 1998–2007 and the regional differences in treatment. Patients and methods Data on 144,607 patients were drawn from the National Patient Register.
The proportion of femoral neck fractures treated with arthroplasty increased from 10% in 1998 to 52% in 2007. The use of intramedullary (IM) nails for pertrochanteric fractures increased from 5% to 20%, at the expense of the use of different sliding hip screws. In subtrochanteric fractures, the use of IM nails increased from 32% to 72%. Re-admissions within 180 days due to hip complications were more common after internal fixation for femoral neck fractures than after arthroplasty, and more common after intramedullary nailing of pertrochanteric fractures than after use of sliding hip screws. Treatment varied substantially within Sweden, particularly regarding the use of IM nails.
An increase in arthroplasties reflects an evidence-based treatment rationale for femoral neck fractures, whereas the increase in use of IM nails in pertrochanteric fractures lacks scientific support. The geographic variations call for national treatment guidelines. Further clinical trials are needed to solve the treatment issues regarding per- and subtrochanteric fractures.
We aimed to explore the effects of polypharmacy and specific drug classes on readmissions and mortality after hip surgery.
We analyzed data on 272 consecutive hip fracture patients (72.1% females; age 82?±?9 years) who underwent acute hip replacement. We collected detailed data on the pharmacological treatment upon admission and discharge. Patients were followed up over a period of 6 months after discharge using the Swedish National Hospital Discharge Register and the Swedish National Cause of Death Register.
After 6 months, 86 patients (31.6%) were readmitted, while 36 patients (13.2%) died. The total number of medications upon discharge was predictive of rehospitalization (odds ratio (OR) 1.08, 95%CI 1.01-1.17, p?=?0.030) but not predictive of mortality. The use of antiosteoporotic agents (OR 1.86, 95%CI 1.06-3.26, p?=?0.03), SSRIs (OR 1.90, 95%CI 1.06-3.42, p?=?0.03), and eye drops (OR 4.12, 95%CI 1.89-8.97, p?=?0.0004) were predictive of rehospitalization. Treatment with vitamin K antagonists (OR 4.29, 95%CI 1.19-15.39, p?=?0.026), thiazides (OR 4.10, 95%CI 1.30-12.91, p?=?0.016), and tramadol (OR 2.84, 95%CI 1.17-6.90, p?=?0.021) predicted readmissions due to a new fall/trauma.
The total number of medications, use of antiosteoporotic agents, SSRIs, and eye drops predicted rehospitalization after hip fracture surgery, while use of vitamin K antagonists, thiazides, and tramadol was associated with readmissions due to a traumatic fall.
Hip fractures and polypharmacy in the elderly. Stimulus Project for the Elderly 2009-2011 (Reg no 2009-11-26). Swedish National Board of Health and Welfare.
Hemiarthroplasties are performed in great numbers worldwide but are seldom registered on a national basis. Our aim was to identify risk factors for reoperation after fracture-related hemiarthroplasty in Norway and Sweden.
A common dataset was created based on the Norwegian Hip Fracture Register and the Swedish Hip Arthroplasty Register. 33,205 hip fractures in individuals > 60 years of age treated with modular hemiarthroplasties were reported for the period 2005-2010. Cox regression analyses based on reoperations were performed (covariates: age group, sex, type of stem and implant head, surgical approach, and hospital volume).
1,164 patients (3.5%) were reoperated during a mean follow-up of 2.7 (SD 1.7) years. In patients over 85 years, an increased risk of reoperation was found for uncemented stems (HR = 2.2, 95% CI: 1.7-2.8), bipolar heads (HR = 1.4, CI: 1.2-1.8), posterior approach (HR = 1.4, CI: 1.2-1.8) and male sex (HR = 1.3, CI: 1.0-1.6). For patients aged 75-85 years, uncemented stems (HR = 1.6, 95% CI: 1.2-2.0) and men (HR = 1.3, CI: 1.1-1.6) carried an increased risk. Increased risk of reoperation due to infection was found for patients aged
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Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality.
The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group).
Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p