Session 1: Trauma

15. November
09:00 - 10:30
Lokale: Lokale 01+02
Chair: Bjarke Viberg and Christina F Frandsen

1. Intensified in-hospital physiotherapy for patients after hip fracture surgery – a randomized feasibility trial
Camilla Kampp Zilmer1, S. Peter Magnusson1,2,3, Inger Birgitte Bährentz1, Thomas Giver Jensen4, Signe Østergaard Zoffmann1, Henrik Palm4, Morten Tange Kristensen1,5, Theresa Bieler1
1 Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark. 2 Institute of Sports Medicine, Department of Orthopaedic Surgery M, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark. 3 Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. 4 Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark. 5 Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.

Background: Intensified acute in-hospital physiotherapy for patients with hip fracture may enhance patient’s ability to regain basic mobility at discharge, but frail patients may not be able to complete such intensified physiotherapy.
Aim: The primary aim was to investigate the feasibility of intensified physiotherapy and secondarily to assess the effect of intensified physiotherapy on regained basic mobility at discharge in patients with hip fracture in a single-center, pragmatic, randomized, unblinded feasibility trial.
Materials and Methods: Sixty home-dwelling patients (41 women/19 men, mean age 79 years) with hip fracture and an inde-pendent pre-fracture basic mobility level were randomized (2:1) to intensified physiotherapy with two daily sessions on weekdays focused on training of basic mobility and weight-bearing activities (n=40) versus usual care physiotherapy once daily (n=20). Outcomes were physiotherapy completion rates during hospitalization (successful, partial, cancellation), causes of non-successful completed physiotherapy and recovery of basic mobility evaluated with the Cumulated Ambulation Score (CAS).
Results: In the intensified physiotherapy group 82% of the sessions were successfully- or partially completed versus 94% in the usual care group. The main reason for not completing physiotherapy was fatigue. At discharge (median of 7 days post-surgery) significantly (p=0.02) more patients in the intensified physiotherapy group (50%) had regained their pre-fracture basic mobility level (CAS=6) than in the usaul care group (16%).
Interpretation / Conclusion: Intensified acute in-hospital physiotherapy seems feasible for patients after hip fracture surgery, and it may enhance recovery. Intensified in-hospital physiotherapy is mainly restricted by fatigue. The sizeable proportion of patients that regained basic mobility at discharge should be further evaluated in a future full-scale randomized controlled trial.

2. Extent of informal caregiving to older persons after hip fracture: a prospective cohort study
Jonas Ammundsen Ipsen 1,2, Viberg Bjarke4,5,6, Draborg Eva3, Hansen Bruun Inge1,2
1. Department of Physical Therapy and Occupational Therapy, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding 2. Department of Regional Health Research, University of Southern Denmark, Odense 3. Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense 4. Department of Orthopaedic Surgery and Traumatology. Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding 5. Department of Orthopaedic Surgery and Traumatology. Odense University Hospital, Odense 6. Department of Clinical Research, University of Southern Denmark, Odense

Background: Patients has a need for help upon discharge to home after hip fracture. To meet the need, patients receive formal care from municipalities and/or informal care (IC) from family/friends. IC can help patients with tasks as collecting medication, buying groceries and showering. Tasks that otherwise would require assistance by formal caregivers. Thus, informal care can cloak an otherwise unmet need for care after hip fracture. Nevertheless, knowledge on informal caregiving are very scarce and current estimates does not fit older home-dwelling persons.
Aim: To explore the extent of informal caregiving to older home-dwelling persons after hip fracture.
Materials and Methods: This prospective study is part of the ‘Rehabilitation for Life’ trial and encompasses a regional hospital and the municipalities of the catchment area. Inclusion criteria was 65+ home-dwelling persons cognitively un- impaired, after hip fracture. Exclusion criteria: short life expectancy and revised surgery. IC was reported in diaries and collected biweekly for 12 weeks after discharge. Outcome was total amount of IC the first 12 weeks after discharge, presented as median and interquartile range. As a sub-analysis, the median amount of IC was used as cut-off for a high and low dependent group.
Results: A total of 226 person’s participated, median age 78 years (73-84) and 60% were women. Ninety- one percent received IC median 28 hours (10, 64). Week 1-2, 72% received IC median 8 hours (0, 28). At week 11-12, 35% received IC median 0 hours (0, 7). Fourty-seven percent were high dependent median 66 hours (46-107), fifty-three percent were low-dependent median 11 hours (2- 20). The high dependent persons had lower mobility and Barthel-20 scores (p=0.02 and p=0.00) and less frequently lived alone (p=0.04).
Interpretation / Conclusion: Even though formal care in Denmark is free of charge, a staggering 91% of the cohort received IC median 28 hours. The proportions and amounts declined during the 12 weeks. At discharge, persons’ high dependent on IC had difficulties with everyday activities and relied more on partners. Indicating that persons with poor mobility, difficulties with everyday tasks and IC may have an unmet need for care.

3. Infection among patients with hip fracture: Predictive ability of Charlson, Elixhauser, Rx-risk, and Nordic multimorbidity indices
Dorete K. Storbjerg1, Nadia R. Gadgaard1, Alma B. Pedersen1
1. Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University;

Background: Post-surgery infection is a common complication among hip fracture patients. Comorbidity indices are important for case-mix confounder adjustment. It is however unknown whether different comorbidity indices have equal predictive ability for post-surgery infections.
Aim: The aim of this population-based cohort study was to evaluate the predictive ability of Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Rx-Risk Index (Rx-Risk), and Nordic Multimorbidity Index (NMI) for any infection up to 1 year after discharge for hip fracture surgery.
Materials and Methods: We included 92,600 hip fracture patients from the Danish Multidisciplinary Hip Fracture Registry (2004-2018) and linked their data to the Danish National Patient Registry and Danish National Prescription Database. Disease categories in the CCI and ECI were based on diagnosis codes, Rx-Risk was based on prescription codes, and NMI was based on both diagnosis- and prescription codes. A 1, 5, and 10-year lookback period were applied to calculate comorbidity indices. Logistic regression was used to calculate c-index to assess discrimination ability of indices individually and combined with a base model of age and sex. Outcomes were any infection in-hospital and any infection 1 year after discharge.
Results: Majority of patients were females (71%), and mean age was 83 years. With a 10-year lookback period, the c-index for individual comorbidity indices for in- hospital infections varied from c-index=0.53 to c- index=0.56, similar to base model alone (c- index=0.56). The predictive ability of comorbidity indices in combination with base model varied from c-index=0.56 to c-index=0.57. Within 1 year after discharge, NMI in combination with base model had best predictive ability for infections (c-index=0.615), followed by CCI and ECI (c-index=0.60) and Rx-Risk (c-index=0.58). Discrimination was similar for all lookback periods.
Interpretation / Conclusion: Comorbidity indices have low predictive ability for infection up to 1 year after hip fracture surgery, similar to predictive ability of age and sex alone. Thus, use of comorbidity indices as a tool for predicting infections is limited. For case-mix adjustment, evaluated comorbidity indices are of equal value.

4. Dual mobility total hip arthroplasty shows similar dislocation rate as hemiarthroplasty in cognitively impaired patients with hip fracture
Christina Frølich Frandsen1, Maiken Stilling1,2,3, Torben Bæk Hansen1,2, Tobias Kvanner Aasvang4, Morten Tange Kristensen4,5,6
1. University Clinic for Hand, Hip and Knee Surgery, Department of Orthopaedics, Gødstrup Hospital, Denmark 2. Department of Clinical Medicine, Aarhus University, Denmark 3. Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark 4. Department of Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark. 5. Department of Physiotherapy, Copenhagen University Hospital, Amager-Hvidovre, Denmark. 6. Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Denmark

Background: Cognitive impairment is seen in approximately 30% of patients with hip fractures and associated with poorer outcome. When treating displaced femoral neck fractures (FNF) hemiarthroplasty (HA) has been the preferred choice of arthroplasty, especially in cognitively impaired patients. A total hip arthroplasty (THA) is considered a relevant alternative but rarely chosen, partly due to an expected increased risk of dislocation compared to HA. However, dual- mobility THA has shown reduced risk of dislocation, but no studies have compared the risk in cognitively impaired patients.
Aim: Primarily, to compare the 90-day dislocation rate of HA versus THA in cognitively impaired patients with FNF. Secondly, to compare the 30-day post-surgery mortality and 30-day post-discharge readmission rates.
Materials and Methods: A consecutive cohort of 436 patients, 65 years or older, with a FNF admitted at two hospitals from January 2018 to June 2019 were evaluated for inclusion. Patients were screened for cognitive impairment upon admission and surgically treated with one hospital using uncemented HA and the other using dual-mobility THA (cemented, uncemented or hybrid). Outcome was extracted from electronic patient records regarding dislocation, readmission (defined as any acute physical hospital contact for any cause), and mortality. Chi-squared and Fishers exact test was used to evaluated between group differences.
Results: 164 out of the 436 patients (38%) with a median age of 85 years had cognitive impairment and were included. 101 patients were treated with HA and 63 with THA. Baseline characteristics of the two groups were similar. The 90-day dislocation rate was 11.9% in the HA-group and 6.5% in the THA-group (p=0.3). A higher readmission rate was observed in the HA- group (37.6%) versus THA-group (19.1%), p=0.01. Corresponding, mortality rates were 15.8% for HA and 14.3% for THA (p=0.8), respectively.
Interpretation / Conclusion: Our findings do not support the hypothesis of a higher risk of dislocation in cognitive impaired patients treated with THA in comparison with the more commonly used HA. Furthermore, the premise of a larger surgical stress when using THA resulting in poorer outcomes such as readmission and mortality is not supported.

5. Low haemoglobin nine days after discharge is associated with reduced mobility two months after hip fracture surgery
Martin Aasbrenn1,2, Thomas Giver Jensen3, Marie West Pedersen4, Nicolai Henning Jensen4, Troels Haxholdt Lunn6,7, Eckart Pressel1,7, Henrik Palm2,3, Anette Ekmann1, Charlotte Suetta1,2,7, Søren Overgaard2,3, Morten Tange Kristensen2,4
1. Department of Geriatric and Palliative Medicine, Bispebjerg-Frederiksberg University Hospital; 2. University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Science; 3. Department of Orthopaedic Surgery and Traumatology, Bispebjerg-Frederiksberg University Hospital; 4. Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg University Hospital; 5. Department of Orthopaedic Surgery, North Zealand Hospital; 6. Department of Anaesthesia and Intensive Care, Bispebjerg-Frederiksberg University Hospital; 7. Copenhagen University Hospital Herlev and Gentofte, Department of Internal Medicine

Background: Haemoglobin is essential for optimal skeletal muscle function and anaemia can be a limiting factor in rehabilitation after acute disease.
Aim: We examined the association between haemoglobin early after discharge and mobility two months after a surgically treated hip fracture.
Materials and Methods: Older patients (=65 years) surgically treated for a hip fracture at Copenhagen University Hospital Bispebjerg and Frederiksberg in 2021 and referred to a outpatient visit two months after discharge were included in the study. Haemoglobin was measured 9 days after discharge from the hospital. New Mobility Score (NMS, 0-9 points) was evaluated by a physiotherapist two months after the admission. Anaemia was defined according to the WHO definition (Haemoglobin <13 g/dL in men, <12 g/dL in women) The association between haemoglobin and NMS was evaluated by linear regression, with age and sex as covariates.
Results: We included 102 patients with a mean (SD) age of 78 (9) years; 75 (74%) were women. Haemoglobin at the 9-day visit was 10.6 g/dL (SD 1.3) and 89 (87%) had anaemia according to the WHO definition. The average NMS two months after the admission was 4.7 (SD 2.2). Low haemoglobin at the 9th day after discharge was associated with reduced NMS at the 2 month control (ß=0.80, 95% CI 0.36-1.38, p=0.002).
Interpretation / Conclusion: In hip fracture patients, we found an association between haemoglobin in the second week after discharge and mobility two months after surgery. Whether treatments to increase haemoglobin in the postoperative phase could enhance rehabilitation and increase recovery should be evaluated in further studies.

6. Quality of care and mortality in hip fracture patients in the course of the COVID pandemic. A population based cohort study
Alma B. Pedersen1,2, Nickolaj Risbo1,2, Bjarke L. Viberg3,4, Henrik Palm5, Niels Dieter Rock3
1. Department of Clinical Epidemiology, Aarhus University Hospital 2. Department of Clinical Medicine, Aarhus University 3. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital 4. Department of Clinical Research, University of Southern Denmark 5. Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg

Background: Few international studies on hip fracture patients suggested no increase in mortality but negative impact on quality of care indicators during COVID compared to pre-COVID period.
Aim: We assessed the quality of in-hospital care for hip fracture patients in Denmark and subsequent mortality before and during the early stages of COVID pandemic.
Materials and Methods: We obtained data on hip fracture patients and quality indicators from the Danish Multidisciplinary Hip Fracture Registry in the COVID period (11 Marts 2019 to 27 January 2021, overall and in five separate periods), and compared these to a pre-COVID period (13 March 2019 to 10 March 2020). Mortality and comorbidity data were from the other Danish medical databases. By different COVID periods, we calculated the proportion of patients (%) that have fulfilled >80% of the relevant quality indicators (a composite score). We used Cox regression to calculate hazard ratios (HR) comparing 30-day mortality in COVID period with pre-COVID period, adjusting for age, gender, comorbidity and residence.
Results: A total of 6575 were treated for hip fracture in the pre-COVID period, and 5919 in the COVID period. Overall, there was no difference in gender, age, fracture and surgery type, body mass index, and comorbidity prevalence between pre-COVID and COVID periods. The composite score was 73% in pre-COVID period, compared to 73% to 80% in the five COVID periods. 30-day mortality was 9.5% in pre-COVID period, compared to 10.8% in the overall COVID period. Mortality varied from 10% in the COVID period with few restrictions, 11.1% in the first national lockdown, to 11.9% in the second national lockdown. HR for mortality was 1.15 (1.02-1.30) in the overall COVID compared to pre-COVID period. HRs varied from 1.07 (0.89-1.29) to 1.31 (1.06-1.62) in five COVID periods. We observed regional variations in the HRs when comparing overall COVID with pre-COVID period.
Interpretation / Conclusion: The quality of in-hospital care for hip fracture patients in Denmark was higher in the COVID compared to pre-COVID period. Unfortunately, 30-day mortality was also higher in the COVID compared to pre-COVID period.

8. Adjusting perioperative methadone dose for elderly and fragile hip fracture patients (MetaHip-trial) - an adaptive dose-finding trial
Jesper Ougaard Schønnemann1, Thomas Strøm 2, Kirsten Specht 3, Kevin Heebøll Nygaard1
1. Department of orthopaedics, University hospital of southern Denmark, Kresten Philipsensvej 15, 6200 Aabenraa 2. Department of anesthesiology and intensive care, University hospital of southern Denmark, Kresten Philipsensvej 15, 6200 Aabenraa 3. Center for COPD, Center for Health and Rehabilitation, Randersgade 60, 2100 København Ø

Background: Hip fractures are associated with severe pain and are sustained by the elderly. Demand for adequate pain relief combined with a low tolerance for drugs makes the analgesic treatment of elderly patients difficult. A single dose of methadone reduces postoperative pain and opioid consumption. However, the safety of using methadone for elderly and fragile patients is unknown.
Aim: Determining the maximal tolerable dose of methadone in elderly hip fracture patients.
Materials and Methods: Hip fracture patients =60 years were consecutively included at a Danish University Hospital in 2023. An adaptive algorithm assigned either 0.10 mg/kg, 0.15 mg/kg, or 0.20 mg/kg of methadone to each patient, administered one time intravenously at the induction of anesthesia. Primary outcome was respiratory depression (RD) and the algorithm would continuously monitor the occurrence throughout the study. The occurrence of RD required a decrease in dosage for the next patient and the absence allowed an increase. This allowed real-time dose adjustment during our study. Data collection was initiated at the post- anesthesia care unit (PACU) and continued at the orthopedic ward where observation charts were completed at 6, 24, and 72 hours after surgery. Secondary outcomes include time spent in PACU, verbal rating pain score (VRS), opioid consumption, and nausea/vomiting.
Results: 30 patients completed the study of which 14 underwent general anesthesia and 16 underwent spinal anesthesia. Three patients experienced RD in PACU. All three received 0.15 mg/kg methadone and they all underwent general anesthesia. None of the patients in spinal anesthesia experienced RD and no patients experienced RD after discharge from PACU. Elderly hip fracture patients undergoing spinal anesthesia did not experience respiratory depression after 0.15 mg/kg methadone.
Interpretation / Conclusion: We have demonstrated that methadone is safe to use during hip fracture surgery. Our data suggest that the maximal tolerable dose of methadone in elderly hip fracture patients undergoing general anesthesia is 0.10 mg/kg. Our results show a great divergence in the tolerability of methadone depending on the type of anesthesia and call for further studies.

9. Quantifying Variability in Daily Accelerations Recorded by Inertial Sensor in Healthy Individuals: Implications for Gait Measurements in Free-Living Environments
Arash Ghaffari1, John Rasmussen 2, Søren Kold1, Ole Rahbek1
1. Interdisciplinary Orthopaedics, Aalborg University Hospital; 2. Department of Materials and Production, Aalborg University.

Background: Gait measurements can vary due to various intrinsic and extrinsic factors, and this variability becomes more pronounced using inertial sensors in a free-living environment. Therefore, identifying and quantifying the sources of variability is essential to ensure measurement reliability and maintain data quality.
Aim: This study aimed to determine the variability of daily accelerations recorded by an inertial sensor in a group of healthy individuals.
Materials and Methods: Ten participants, including six females, with a mean age of 50 years (range: 29–61) and BMI of 26.9 kg/m² (range: 21.4–36.8), were included. A single accelerometer continuously recorded lower limb accelerations over two weeks. We extracted and analyzed the accelerations of three consecutive strides within walking bouts if the time difference between the bouts was more than two hours. Multivariate mixed-effects modeling was performed on both the discretized acceleration waveforms at 101 points (0-100) and the harmonics of the signals in the frequency domain to determine the variance components for different subjects, days, bouts, and steps as the random effect variables. Intraclass correlation coefficients (ICCs) were calculated for between-day, between-bout, and between-step comparisons.
Results: The results showed that the ICCs for the between-day, between-bout, and between-step comparisons were 0.73, 0.82, 0.99 for the vertical axis; 0.64, 0.75, 0.99 for the anteroposterior axis; and 0.55, 0.96, 0.97 for the mediolateral axis. For the signal harmonics, the respective ICCs were 0.98, 0.98, 0.99 for the vertical axis; 0.54, 0.93, 0.98 for the anteroposterior axis; and 0.69, 0.78, 0.95 for the mediolateral axis.
Interpretation / Conclusion: Overall, this study demonstrated that accelerations recorded continuously for multiple days in a free-living environment exhibit high variability, mainly between subjects, with some variability arising from differences between days and walking bouts, particularly in the anteroposterior and mediolateral axes. However, reliable and repeatable gait measurements can be obtained by identifying and quantifying the sources of variability.

10. Risk of secondary surgery following surgical treatment of fractures in adults
Anders Bo Rønnegaard1, Signe Steenstrup Jensen1, Peter Toft Tengberg2, Per Hviid Gundtoft1,3, Bjarke Viberg1,4
1. Department of Orthopedic Surgery and Traumatology, Kolding Hospital - part of Hospital Lillebaelt 2. Department of Orthopedic Surgery, Hvidovre Hospital 3. Department of Orthopedic Surgery, Aarhus University Hospital 4. Department of Orthopedic Surgery, Odense University Hospital

Background: The risk of secondary surgery following primary, fracture-related surgery of the extremities is either unknown or only described in a limited number of studies. In order to inform patients adequately it is important to have studies concerning large cohorts for statistical accuracy and subgroup analyses.
Aim: To estimate the risk of experiencing any secondary, musculoskeletal surgery within 2 years of primary fracture-related surgery using osteosynthesis.
Materials and Methods: We performed a nationwide register study on adult patients surgically treated for fractures at a Danish hospital in 2016 with 2 years of follow-up using data from the Danish Fracture Database, the Danish National Patient Registry and the Danish Civil Registration System. Primary outcome was risk of any secondary, musculoskeletal surgery defined as any surgical procedure code within 2 years after primary surgery. Secondary outcome was risk of major reoperation defined as reosteosynthesis, nonunion, arthroplasty, and deep infection. We calculated risk using the cumulative incidence function accounting for death as a competing risk and presented with 95% confidence intervals (CI) overall and stratified on age, sex and anatomical area.
Results: We included 9,719 adult patients of which 63% were female and the median age was 70 years (20–100). Fractures of the upper leg were most frequent. The overall risk of secondary musculoskeletal surgery was 20% (95% CI (19.1–20.6)) and for major reoperation it was 8% (95% CI (7.1–8.2)). Males had a higher risk of all outcomes compared to females. Across anatomical areas risk of secondary surgery ranged from 11% (95% CI 9.9–11.7) in the upper leg to 70% (95% CI 66.6–73.6) in the hand. For major reoperations it ranged from 4% (95% CI 3.5–5.3) in the forearm to 13% (95% CI 11.2–14.8) in the ankle and foot.
Interpretation / Conclusion: This study provide estimates for the risk of experiencing secondary, musculoskeletal surgery and major reoperations following primary, fracture- related surgery of the extremities, which can be used by orthopedic surgeons counselling patients prior to fracture-related surgical procedures.