Session 8: Trauma
14. November
14:30 - 16:00
Lokale: Sal B
Chair: Rikke Thorninger & Kristoffer Hare
Michael Houlind Larsen1,3, Per Hviid Gundtoft1,2, Bjarke Viberg1,3
1. Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt Kolding- University Hospital of Southern Denmark 2.Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 3. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: In a world where aging populations strain healthcare and economic resources, effective tools for identifying vulnerable elderly individuals with lower extremity fractures are crucial.
Aim: To study how surgically treated fracture in femur, lower leg, foot/ankle affects 30- and 365-days mortality in individuals above 65 years.
Materials and Methods: We extracted data from the Danish National Patient Register on all patients aged 65 years and above, diagnosed with a lower extremity fracture (S72*, S82*, S92*) and treated with surgical procedures in the period 1998-2017. The primary outcomes were 30- and 365-days mortality. Secondary outcomes were mortality rates by fracture site (femur, lower leg, foot/ankle), sex, age groups (5-year span), and comorbidity level calculated by Charlson Comorbidity Index (none: 0, low: 1-2, and high: =3).
Results: There were 182,013 operatively treated lower extremity fractures recorded in individuals above 65 years, and 73% occurred in females. The 30- day mortality rate for the total cohort was 9% and it was 26% for 365 days. The 30-day mortality rate was 10% for femoral fractures in comparison to 2% for lower leg and 1% for foot/ankle. The mortality rates were similar in femoral fractures regardless of location (8-11%). The differences between fractures sites at 30-days mortality were similar for the 365-day mortality with 29% for femoral fractures, 8% for lower leg, and 6% for foot/ankle. Men with a femoral fracture had a higher 30-day mortality rate than women (15% versus 8%) as well as 365-days (37% vs 26%). Generally, the mortality rate significantly increased with the age of the patients and with higher CCI scores. However, the location of the fracture was less important for 365-day mortality rate in age above 85 years as comparable high mortality rates were observed across fracture location groups.
Interpretation / Conclusion: There was an observed higher risk of mortality in surgically treated femoral fractures and the mortality rates seems to rapidly decline when the fracture is below the knee. This could indicate that a femoral fracture, regardless of location, is a fragility fracture and patient care should be accordingly.
1. Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt Kolding- University Hospital of Southern Denmark 2.Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital 3. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital
Background: In a world where aging populations strain healthcare and economic resources, effective tools for identifying vulnerable elderly individuals with lower extremity fractures are crucial.
Aim: To study how surgically treated fracture in femur, lower leg, foot/ankle affects 30- and 365-days mortality in individuals above 65 years.
Materials and Methods: We extracted data from the Danish National Patient Register on all patients aged 65 years and above, diagnosed with a lower extremity fracture (S72*, S82*, S92*) and treated with surgical procedures in the period 1998-2017. The primary outcomes were 30- and 365-days mortality. Secondary outcomes were mortality rates by fracture site (femur, lower leg, foot/ankle), sex, age groups (5-year span), and comorbidity level calculated by Charlson Comorbidity Index (none: 0, low: 1-2, and high: =3).
Results: There were 182,013 operatively treated lower extremity fractures recorded in individuals above 65 years, and 73% occurred in females. The 30- day mortality rate for the total cohort was 9% and it was 26% for 365 days. The 30-day mortality rate was 10% for femoral fractures in comparison to 2% for lower leg and 1% for foot/ankle. The mortality rates were similar in femoral fractures regardless of location (8-11%). The differences between fractures sites at 30-days mortality were similar for the 365-day mortality with 29% for femoral fractures, 8% for lower leg, and 6% for foot/ankle. Men with a femoral fracture had a higher 30-day mortality rate than women (15% versus 8%) as well as 365-days (37% vs 26%). Generally, the mortality rate significantly increased with the age of the patients and with higher CCI scores. However, the location of the fracture was less important for 365-day mortality rate in age above 85 years as comparable high mortality rates were observed across fracture location groups.
Interpretation / Conclusion: There was an observed higher risk of mortality in surgically treated femoral fractures and the mortality rates seems to rapidly decline when the fracture is below the knee. This could indicate that a femoral fracture, regardless of location, is a fragility fracture and patient care should be accordingly.
Alec Friswold, Devon Brameier, Faith Selzer, Liqin Wang, Li Zhou, Michael Weaver, Arvind von Keudell
Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Background: Hip fractures impose substantial mortality, morbidity, and cost. Alternative payment models may control costs; however, patient heterogeneity necessitates potential risk adjustment. Frailty is associated with higher mortality and morbidity and may be a risk factor for higher hospital costs. The Frailty Index (FI) is a tool that quantifies a patient’s physiologic reserve, e.g. frailty, based on the accumulated deficits identified by a Comprehensive Geriatric Assessment. The relationship between FI and hospital resource utilization in the hip fracture population has not yet been investigated.
Aim: This study investigates the unadjusted association between Frailty Index and treatment-related cost for hip fractures.
Materials and Methods: Analysis included 326 patients over 65 who underwent surgical repair of femoral neck or intertrochanteric hip fracture between 2018-2020 at a Level 1 Trauma Center. FI was calculated by geriatricians performing a comprehensive history and physical examination. Patients were stratified into Non-frail (FI:0-0.21), Moderately Frail (FI:0.21-0.45) and Severely Frail (FI>0.45). Financial data was obtained for each episode. Primary outcome was a percentage difference in total cost of care, direct cost, and revenue relative to non-frail patients as the comparison group.
Results: Compared to non-frail patients, severely frail patients were found to have, on average, a 20% higher total cost of in-hospital care (p<.05), 17% higher direct cost of care (p<0.05), and 10% revenue (p<0.05). Moderately frail patients were found to have 12% higher total cost of care (p<0.05), 11% higher direct cost of care (p<0.05), and 5% higher revenue (p=0.29) compared to the non-frail group.
Interpretation / Conclusion: Greater degrees of frailty are associated with higher cost of care, suggesting frailty could be used to risk adjust payments. The increase in revenue for moderately frail and severely frail patients does not meet the increase in total or direct cost, suggesting current payment models disincentivize caring for frailer patients.
Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Background: Hip fractures impose substantial mortality, morbidity, and cost. Alternative payment models may control costs; however, patient heterogeneity necessitates potential risk adjustment. Frailty is associated with higher mortality and morbidity and may be a risk factor for higher hospital costs. The Frailty Index (FI) is a tool that quantifies a patient’s physiologic reserve, e.g. frailty, based on the accumulated deficits identified by a Comprehensive Geriatric Assessment. The relationship between FI and hospital resource utilization in the hip fracture population has not yet been investigated.
Aim: This study investigates the unadjusted association between Frailty Index and treatment-related cost for hip fractures.
Materials and Methods: Analysis included 326 patients over 65 who underwent surgical repair of femoral neck or intertrochanteric hip fracture between 2018-2020 at a Level 1 Trauma Center. FI was calculated by geriatricians performing a comprehensive history and physical examination. Patients were stratified into Non-frail (FI:0-0.21), Moderately Frail (FI:0.21-0.45) and Severely Frail (FI>0.45). Financial data was obtained for each episode. Primary outcome was a percentage difference in total cost of care, direct cost, and revenue relative to non-frail patients as the comparison group.
Results: Compared to non-frail patients, severely frail patients were found to have, on average, a 20% higher total cost of in-hospital care (p<.05), 17% higher direct cost of care (p<0.05), and 10% revenue (p<0.05). Moderately frail patients were found to have 12% higher total cost of care (p<0.05), 11% higher direct cost of care (p<0.05), and 5% higher revenue (p=0.29) compared to the non-frail group.
Interpretation / Conclusion: Greater degrees of frailty are associated with higher cost of care, suggesting frailty could be used to risk adjust payments. The increase in revenue for moderately frail and severely frail patients does not meet the increase in total or direct cost, suggesting current payment models disincentivize caring for frailer patients.
Jonas Ammundsen Ipsen 1, 2, Jan Abel Olsen8, Bjarke Viberg 3,4,5 , Lars T. Pedersen 1,2,6, Inge Hansen Bruun 1,2, Eva Draborg7
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. Department of Orthopaedic Surgery and Traumatology. Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding 4. Department of Orthopaedic Surgery and Traumatology. Odense University Hospital, Odense 5. Department of Clinical Research, University of Southern Denmark, Odense 6. Department of Health Education, University College South Denmark, Esbjerg 7. Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense 8. UiT The Arctic University of Norway, Department of Community Medicine, Tromsø
Background: Hip fracture treatment is costly. However, costs may depend on patient characteristics and type of treatment. This should be considered when planning the rehabilitation, but the cost has not been estimated yet, nor has any difference between patient groups been identified.
Aim: To provide new knowledge on how costs of hip fracture treatment differ across subgroups of patients.
Materials and Methods: This is a planned exploratory outcome study from a prospective study. It encompasses a regional hospital and the municipalities of the catchment area. Inclusion criteria were 65+ years old community-dwelling persons cognitively unimpaired after hip fracture. Exclusion criteria were short life expectancy and revision surgery. Healthcare costs were collected from hospitals and municipalities and reported as the median treatment cost. Depending on patient characteristics and treatment, cost differences were reported in medians and assessed with Wilcoxon or Kruskal-Wallis rank tests.
Results: In total, 245 patients participated; mean age of 78 (SD 7), 66% female, 50% lived alone, and mean BMI 24.9 (SD 4). The median treatment cost was 102,236 DKK. Costs differed significantly along the following patient characteristics: age above 85 years cost 49% more (P=0.00) than the median treatment cost; ASA >3 cost 42% more (p=0.00); living alone cost 52% more (p=0.00); patients needing help from others to walk cost 56% more (p=0.00), while sex (p=0.25) and BMI (p=0.24) did not affect costs. Concerning type of treatment, patients with internal fixation (sliding hip screws or intramedullary nails) cost 48% more (p=0.00) than patients with arthroplasty. The main reasons for increased cost were in- hospital stay, outpatient contacts, home care and community nursing. Rehabilitation costs were not associated with patient characteristics or treatment.
Interpretation / Conclusion: The mean cost of treating a hip fracture patient was 102,236 DKK. The cost was significantly higher if patients were older, more comorbid, lived alone, poorly mobilized or treated with internal fixation. The treatment courses offered to these patients are likely the ones we need to improve as their need for rehabilitation is higher.
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. Department of Orthopaedic Surgery and Traumatology. Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding 4. Department of Orthopaedic Surgery and Traumatology. Odense University Hospital, Odense 5. Department of Clinical Research, University of Southern Denmark, Odense 6. Department of Health Education, University College South Denmark, Esbjerg 7. Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense 8. UiT The Arctic University of Norway, Department of Community Medicine, Tromsø
Background: Hip fracture treatment is costly. However, costs may depend on patient characteristics and type of treatment. This should be considered when planning the rehabilitation, but the cost has not been estimated yet, nor has any difference between patient groups been identified.
Aim: To provide new knowledge on how costs of hip fracture treatment differ across subgroups of patients.
Materials and Methods: This is a planned exploratory outcome study from a prospective study. It encompasses a regional hospital and the municipalities of the catchment area. Inclusion criteria were 65+ years old community-dwelling persons cognitively unimpaired after hip fracture. Exclusion criteria were short life expectancy and revision surgery. Healthcare costs were collected from hospitals and municipalities and reported as the median treatment cost. Depending on patient characteristics and treatment, cost differences were reported in medians and assessed with Wilcoxon or Kruskal-Wallis rank tests.
Results: In total, 245 patients participated; mean age of 78 (SD 7), 66% female, 50% lived alone, and mean BMI 24.9 (SD 4). The median treatment cost was 102,236 DKK. Costs differed significantly along the following patient characteristics: age above 85 years cost 49% more (P=0.00) than the median treatment cost; ASA >3 cost 42% more (p=0.00); living alone cost 52% more (p=0.00); patients needing help from others to walk cost 56% more (p=0.00), while sex (p=0.25) and BMI (p=0.24) did not affect costs. Concerning type of treatment, patients with internal fixation (sliding hip screws or intramedullary nails) cost 48% more (p=0.00) than patients with arthroplasty. The main reasons for increased cost were in- hospital stay, outpatient contacts, home care and community nursing. Rehabilitation costs were not associated with patient characteristics or treatment.
Interpretation / Conclusion: The mean cost of treating a hip fracture patient was 102,236 DKK. The cost was significantly higher if patients were older, more comorbid, lived alone, poorly mobilized or treated with internal fixation. The treatment courses offered to these patients are likely the ones we need to improve as their need for rehabilitation is higher.
Henriette Duborg Brink1, Jesper O. Schønnemann1
1. Department of Orthopaedics. University Hospital of Southern Denmark, Aabenraa
Background: Malleolar fractures are prone to poor healing and a higher risk of infection following surgery. Complications include tissue swelling due to soft tissue injury, hemorrhage and secondary inflammation. The skin covering the malleolus lacks significant muscle or fat tissue, posing a unique challenge for skin closure. Studies have demonstrated that intermittent pneumatic foot-compression (IPC) may reduce swelling and promote faster healing, potentially lowering the incidence of superficial infections.
Aim: To investigate if in-cast IPC 24 hours post- surgery could reduce the number of patients with insufficient wound healing.
Materials and Methods: A 2-year prospective study of patients with malleolar fractures (AO type 44-A, 44-B, 44- C) requiring surgery with internal fixation. The first year we treated patients with usual cast-immobilization post-surgery. The following year we treated patients with in- cast IPC 24 hours post-surgery. Patients who were not fitted with an IPC due to a shortage, were automatically moved to the control group. Patients were seen in a postoperative ambulatory follow-up by an orthopedic surgeon at 14 days and 6 weeks. The registration was made in the patients file and based on objective findings. Successful wound healing was defined as removal of all stitches and no wound dehiscence. The amount of major complications was followed up for 6 months.
Results: We included 179 patients with a mean age of 55. 118 was wearing the usual cast- immobilization and 61 was wearing in-cast IPC 24 hours post-surgery. Using monte carlo simulations, by a univariate logistic regression, we calculated that the odds ratio must be at or above 3 to achieve a strength of 80% and a significance level of 0.05. We registered that 49.2% of patients in the IPC group had insufficient wound healing at the 14- day follow-up compared to 39.8% in the control group. At 6-week follow-up 38.3% in the IPC group and 27.1% in the control group, still had insufficient wound healing.
Interpretation / Conclusion: The utilization of in-cast intermittent pneumatic foot compression did not result in significant healing improvements at the 14-day follow-up and did not demonstrate a notable effect in reducing the incidence of wound healing complications.
1. Department of Orthopaedics. University Hospital of Southern Denmark, Aabenraa
Background: Malleolar fractures are prone to poor healing and a higher risk of infection following surgery. Complications include tissue swelling due to soft tissue injury, hemorrhage and secondary inflammation. The skin covering the malleolus lacks significant muscle or fat tissue, posing a unique challenge for skin closure. Studies have demonstrated that intermittent pneumatic foot-compression (IPC) may reduce swelling and promote faster healing, potentially lowering the incidence of superficial infections.
Aim: To investigate if in-cast IPC 24 hours post- surgery could reduce the number of patients with insufficient wound healing.
Materials and Methods: A 2-year prospective study of patients with malleolar fractures (AO type 44-A, 44-B, 44- C) requiring surgery with internal fixation. The first year we treated patients with usual cast-immobilization post-surgery. The following year we treated patients with in- cast IPC 24 hours post-surgery. Patients who were not fitted with an IPC due to a shortage, were automatically moved to the control group. Patients were seen in a postoperative ambulatory follow-up by an orthopedic surgeon at 14 days and 6 weeks. The registration was made in the patients file and based on objective findings. Successful wound healing was defined as removal of all stitches and no wound dehiscence. The amount of major complications was followed up for 6 months.
Results: We included 179 patients with a mean age of 55. 118 was wearing the usual cast- immobilization and 61 was wearing in-cast IPC 24 hours post-surgery. Using monte carlo simulations, by a univariate logistic regression, we calculated that the odds ratio must be at or above 3 to achieve a strength of 80% and a significance level of 0.05. We registered that 49.2% of patients in the IPC group had insufficient wound healing at the 14- day follow-up compared to 39.8% in the control group. At 6-week follow-up 38.3% in the IPC group and 27.1% in the control group, still had insufficient wound healing.
Interpretation / Conclusion: The utilization of in-cast intermittent pneumatic foot compression did not result in significant healing improvements at the 14-day follow-up and did not demonstrate a notable effect in reducing the incidence of wound healing complications.
Damgren Vesterager Jeppe 1, Torngren Hannes 1, Elsoe Rasmus1, Larsen Peter1
Department of Orthopaedics, Aalborg University Hospital
Background: Patella fracture is an injury that affects individuals of all age- and gender-groups, accounting for approximately 1% of all fractures in adults with an incidence of 13,1/100,000/year Complications to surgical treatment of patella fractures are commonly reported, Previous reviews, Dy et al, 2011, reported 33.6% re-operations, 3.3% infections, and 1.3% cases of nonunion in surgical treated patella fractures. In recent years several large-scale studies have been added to the literature enables for more accurate information regarding the high risk of complications to surgical treatment of patella fractures. At present, there is a need for a comprehensive literature review to identify the most frequent and severe complications.
Aim: The aim of this systematic review and proportional meta-analysis was to identify complications to surgical treatment of patella fractures and to estimate their incidence. We extend existing knowledge in this topic by including several more recent and large-scale studies.
Materials and Methods: After searching in PubMed, MEDLINE, EMBASE, Cochrane Library, and OpenGrey, all studies from after year 2000, study populations >100 patients, patients >18 years and follow-up >30 days were included. Two independent authors (JV,HT) assessed the literature search and extracted the data. Risk of bias was assessed using Newcastle-Ottawa Quality assessment Scale. Meta-nalysis was performed on complications pooled in infections, nonunion, symptomatic implant removal and fixation failure.
Results: Data of complications were available from 14 studies including a pool of 5659 patients. The most common complication was symptomatic implant removal affecting 29.6% (95%-CI: 21.5 - 37.7). Other complications stated were fixation failure (5.2 %, 95%-CI: 4.0 - 6.3), infections (3.1%, 95%-CI: 1.7 - 4.5) and nonunion (1.7% (95%-CI: 0 – 3.7). All studies were rated with low risk of bias, with NOS ranging from 6 to 8.
Interpretation / Conclusion: Surgically treatment of patella fractures was associated with a high risk of complications. The most common complication was symptomatic implant removal affecting 29.6% of patients. Other complications stated were fixation failure 5.2%, infections 3.1% and nonunion 1.7%.
Department of Orthopaedics, Aalborg University Hospital
Background: Patella fracture is an injury that affects individuals of all age- and gender-groups, accounting for approximately 1% of all fractures in adults with an incidence of 13,1/100,000/year Complications to surgical treatment of patella fractures are commonly reported, Previous reviews, Dy et al, 2011, reported 33.6% re-operations, 3.3% infections, and 1.3% cases of nonunion in surgical treated patella fractures. In recent years several large-scale studies have been added to the literature enables for more accurate information regarding the high risk of complications to surgical treatment of patella fractures. At present, there is a need for a comprehensive literature review to identify the most frequent and severe complications.
Aim: The aim of this systematic review and proportional meta-analysis was to identify complications to surgical treatment of patella fractures and to estimate their incidence. We extend existing knowledge in this topic by including several more recent and large-scale studies.
Materials and Methods: After searching in PubMed, MEDLINE, EMBASE, Cochrane Library, and OpenGrey, all studies from after year 2000, study populations >100 patients, patients >18 years and follow-up >30 days were included. Two independent authors (JV,HT) assessed the literature search and extracted the data. Risk of bias was assessed using Newcastle-Ottawa Quality assessment Scale. Meta-nalysis was performed on complications pooled in infections, nonunion, symptomatic implant removal and fixation failure.
Results: Data of complications were available from 14 studies including a pool of 5659 patients. The most common complication was symptomatic implant removal affecting 29.6% (95%-CI: 21.5 - 37.7). Other complications stated were fixation failure (5.2 %, 95%-CI: 4.0 - 6.3), infections (3.1%, 95%-CI: 1.7 - 4.5) and nonunion (1.7% (95%-CI: 0 – 3.7). All studies were rated with low risk of bias, with NOS ranging from 6 to 8.
Interpretation / Conclusion: Surgically treatment of patella fractures was associated with a high risk of complications. The most common complication was symptomatic implant removal affecting 29.6% of patients. Other complications stated were fixation failure 5.2%, infections 3.1% and nonunion 1.7%.
Soham Ghoshal1, Alex Farid1, Tynan Friend1, Michael Gustin1, Derek Stenquist1, Nishant Suneja1, Michael Weaver1, Arvind Von Keudell1
1. Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA
Background: Lateral compression type 1 (LC1) fractures are the most common type of pelvic fractures, with studies demonstrating that they account for nearly two-thirds of all pelvic fractures. Historically, LC1 fractures have been difficult to manage and there has been controversy over whether patients should be treated operatively or non-operatively. Traditionally, operative management has been reserved for treatment of unstable fractures to prevent displacement. Studies of operative management have demonstrated improved time to mobilization, decreased pain, and improved functional status in patients with LC1 fractures. However, while operative management has shown a trend toward improving quality of life (as measured by EQ-5D), recent systematic reviews have not found any statistical differences in length of hospital stay or complication rates between patients undergoing operative vs nonoperative management for LC1 fractures.
Aim: This study aims to compare the cost- effectiveness of operative treatment with that of nonoperative treatment of LC1 pelvic fractures.
Materials and Methods: We developed a multi-arm decision tree consisting of conservative management, initial exam under anesthesia for suspected unstable fractures, and direct operative treatment. Cost- effectiveness analysis was carried out using two-year EQ-5D utility data from the literature. Surgical costs included the ambulatory surgical fee, physician fee and anesthesia fee. We used rollback analysis to determine the cost- effectiveness of each treatment option, presented as the incremental cost effectiveness ratio (ICER), utilizing a $50,000 willingness-to- pay (WTP) threshold.
Results: Rollback analysis revealed that compared to nonoperative treatment, exam under anesthesia cost $1175.66 more, while operative treatment cost $3722.92 more and yielded comparable EQ-5D scores. The ICER for undergoing exam under anesthesia compared to non-operative treatment was -$127,510 at 2-year follow-up. The ICER for undergoing operative treatment was lower, at -$136,095 at 2-year follow-up.
Interpretation / Conclusion: Nonoperative management was found to be more cost effective than operative management of LC1 fractures.
1. Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA
Background: Lateral compression type 1 (LC1) fractures are the most common type of pelvic fractures, with studies demonstrating that they account for nearly two-thirds of all pelvic fractures. Historically, LC1 fractures have been difficult to manage and there has been controversy over whether patients should be treated operatively or non-operatively. Traditionally, operative management has been reserved for treatment of unstable fractures to prevent displacement. Studies of operative management have demonstrated improved time to mobilization, decreased pain, and improved functional status in patients with LC1 fractures. However, while operative management has shown a trend toward improving quality of life (as measured by EQ-5D), recent systematic reviews have not found any statistical differences in length of hospital stay or complication rates between patients undergoing operative vs nonoperative management for LC1 fractures.
Aim: This study aims to compare the cost- effectiveness of operative treatment with that of nonoperative treatment of LC1 pelvic fractures.
Materials and Methods: We developed a multi-arm decision tree consisting of conservative management, initial exam under anesthesia for suspected unstable fractures, and direct operative treatment. Cost- effectiveness analysis was carried out using two-year EQ-5D utility data from the literature. Surgical costs included the ambulatory surgical fee, physician fee and anesthesia fee. We used rollback analysis to determine the cost- effectiveness of each treatment option, presented as the incremental cost effectiveness ratio (ICER), utilizing a $50,000 willingness-to- pay (WTP) threshold.
Results: Rollback analysis revealed that compared to nonoperative treatment, exam under anesthesia cost $1175.66 more, while operative treatment cost $3722.92 more and yielded comparable EQ-5D scores. The ICER for undergoing exam under anesthesia compared to non-operative treatment was -$127,510 at 2-year follow-up. The ICER for undergoing operative treatment was lower, at -$136,095 at 2-year follow-up.
Interpretation / Conclusion: Nonoperative management was found to be more cost effective than operative management of LC1 fractures.
Jacob Schade Engbjerg1,2,4, Rune Dall Jensen2,4, Michael Tjørnild1, Rikke Thorninger 3, Jan Duedal Rölfing2,3,4
1 Department of Orthopaedics, Regional Hospital Randers. 2 MidtSim, Central Denmark Region. 3 Dept. of Orthopaedics, Aarhus University Hospital. 4 Dept. of Clinical Medicine, HEALTH, Aarhus University
Background: Femoral neck fractures (FNF) have a high mortality rate. There is conflicting literature on the association between surgical delay and morbidity and mortality.
Aim: This study investigated the relationship between surgery-delay and the complication and mortality rates within the first two years (y).
Materials and Methods: Retrospective review of FNF patients treated with DHS at Regional Hospital Randers 2015- 2021 (n=325). Patients were identified using Central Denmark Region’s Business Intelligence-portal. Primary composite outcome: complications identified on x-rays (cut-out, non-union, head necrosis), reoperation and death within 2 years. Surgery- delay was defined as time from the diagnostic x- ray to operation start. Comorbidities (CCI-score) and mortality were based on chart review. Data are reported as median and IQR and assessed with Mann Whitney test.
Results: The mortality rate was 16% and 26% within 1 and 2 years. The complication rate was 47/325 patients <1 y, and 52/325 patients < 2 y. Overall surgery-delay was 7.9 h (5;14). Delay was significantly associated with 1-y mortality, p < 0.01; 10.9 h (7;17) for patients deceased < 1 y and 7.5 h (5;14) for patients still alive. This was still significant after 2 years. Delay was not associated with risk of complications 1 y after surgery for Garden type 1/2, p =0.05, nor Garden type 3/4, p=0.33. Delay was associated with risk of complications 2 y after surgery for Garden type 1/2, 13.5 h (8;16) for patients with complications and 7.6 h (5;15) for patients without complications, p=0.046. No association for Garden type 3/4, p=0.31. CCI-score was not associated with 1-y or 2-y risk of complications, p =0.77; p=0.74. CCI-score was significantly associated with both 1-y mortality, p=0.0003, 2 (1;3) vs. 1 (0;2) and 2-y mortality, p<0.001, 2 (1;2) vs. 0 (0;3).
Interpretation / Conclusion: We report significant association between surgery-delay and mortality rates in FNF even though overall delay is below 24 hours. Further, we report significant association between surgery-delay and the risk of complication/reoperation 2 y after surgery for garden type 1/2 fractures. Unsurprisingly, CCI- score is significantly correlated with risk for death 1y and 2y after surgery.
1 Department of Orthopaedics, Regional Hospital Randers. 2 MidtSim, Central Denmark Region. 3 Dept. of Orthopaedics, Aarhus University Hospital. 4 Dept. of Clinical Medicine, HEALTH, Aarhus University
Background: Femoral neck fractures (FNF) have a high mortality rate. There is conflicting literature on the association between surgical delay and morbidity and mortality.
Aim: This study investigated the relationship between surgery-delay and the complication and mortality rates within the first two years (y).
Materials and Methods: Retrospective review of FNF patients treated with DHS at Regional Hospital Randers 2015- 2021 (n=325). Patients were identified using Central Denmark Region’s Business Intelligence-portal. Primary composite outcome: complications identified on x-rays (cut-out, non-union, head necrosis), reoperation and death within 2 years. Surgery- delay was defined as time from the diagnostic x- ray to operation start. Comorbidities (CCI-score) and mortality were based on chart review. Data are reported as median and IQR and assessed with Mann Whitney test.
Results: The mortality rate was 16% and 26% within 1 and 2 years. The complication rate was 47/325 patients <1 y, and 52/325 patients < 2 y. Overall surgery-delay was 7.9 h (5;14). Delay was significantly associated with 1-y mortality, p < 0.01; 10.9 h (7;17) for patients deceased < 1 y and 7.5 h (5;14) for patients still alive. This was still significant after 2 years. Delay was not associated with risk of complications 1 y after surgery for Garden type 1/2, p =0.05, nor Garden type 3/4, p=0.33. Delay was associated with risk of complications 2 y after surgery for Garden type 1/2, 13.5 h (8;16) for patients with complications and 7.6 h (5;15) for patients without complications, p=0.046. No association for Garden type 3/4, p=0.31. CCI-score was not associated with 1-y or 2-y risk of complications, p =0.77; p=0.74. CCI-score was significantly associated with both 1-y mortality, p=0.0003, 2 (1;3) vs. 1 (0;2) and 2-y mortality, p<0.001, 2 (1;2) vs. 0 (0;3).
Interpretation / Conclusion: We report significant association between surgery-delay and mortality rates in FNF even though overall delay is below 24 hours. Further, we report significant association between surgery-delay and the risk of complication/reoperation 2 y after surgery for garden type 1/2 fractures. Unsurprisingly, CCI- score is significantly correlated with risk for death 1y and 2y after surgery.
Simon Storgaard Jensen1, Lei Wang1, Nadia R. Gadgaard1, Henrik T. Sørensen1, Alma B. Pedersen1
1. Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
Background: Orthopedic registries have provided valuable input about risk for and prognosis after hip fracture. However, registries are often limited by the lack of data on lifestyle factors, health-related quality of life and behavior, and social background. These data are readily available in surveys.
Aim: We aimed to examine if participants of the Danish self-reported questionnaire-based public health survey “How are you” are representative of hip fracture patients.
Materials and Methods: Hip fracture patients were identified in the Danish Multidisciplinary Hip Fracture Register and combined with survey data (from 2010, 2013, 2017), and data from the Danish medical databases on the individual-level. We calculated proportions of a wide range of variables, comparing patients who had and those who had not participated in surveys before hip fracture.
Results: We included 92,600 fracture patients, of which 3,557 (3.8%) participated in surveys. The median time from survey to hip fracture was 3.8 years. Participants and non-participants had sex distribution of 34% and 29%, and proportion of patients aged 75+ years of 77% and 81%. The two groups had similar proportion of patients with no comorbidity (54% vs 55%). Participants used slightly more anticoagulants and statins, but less psychiatric medications. The proportion of patients with high income and high educational level was 17% vs 9% and 14% vs 8% for participants vs non-participants, respectively. The proportion of patients cohabiting was 40% vs 30% for participants vs non- participants.
Interpretation / Conclusion: The survey data provided a sample that appeared to be representative of the entire hip fracture population based on several patient characteristics. Thus, the survey data could be a valuable tool for further understanding the risk and outcome of hip fracture patients. Slight differences were observed for medication and socioeconomic markers.
1. Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
Background: Orthopedic registries have provided valuable input about risk for and prognosis after hip fracture. However, registries are often limited by the lack of data on lifestyle factors, health-related quality of life and behavior, and social background. These data are readily available in surveys.
Aim: We aimed to examine if participants of the Danish self-reported questionnaire-based public health survey “How are you” are representative of hip fracture patients.
Materials and Methods: Hip fracture patients were identified in the Danish Multidisciplinary Hip Fracture Register and combined with survey data (from 2010, 2013, 2017), and data from the Danish medical databases on the individual-level. We calculated proportions of a wide range of variables, comparing patients who had and those who had not participated in surveys before hip fracture.
Results: We included 92,600 fracture patients, of which 3,557 (3.8%) participated in surveys. The median time from survey to hip fracture was 3.8 years. Participants and non-participants had sex distribution of 34% and 29%, and proportion of patients aged 75+ years of 77% and 81%. The two groups had similar proportion of patients with no comorbidity (54% vs 55%). Participants used slightly more anticoagulants and statins, but less psychiatric medications. The proportion of patients with high income and high educational level was 17% vs 9% and 14% vs 8% for participants vs non-participants, respectively. The proportion of patients cohabiting was 40% vs 30% for participants vs non- participants.
Interpretation / Conclusion: The survey data provided a sample that appeared to be representative of the entire hip fracture population based on several patient characteristics. Thus, the survey data could be a valuable tool for further understanding the risk and outcome of hip fracture patients. Slight differences were observed for medication and socioeconomic markers.
Rasmus Jorgensen2,3, Rasmus Elsoe2, Pernille Bønneland2, Peter Larsen1,2
1 Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark 2 Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark. 3 Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.
Background: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is one commonly used knee- specific patient-reported outcome instrument, among several others, to capture the patient- perceived outcomes following patella fractures. However, to the authors’ knowledge, none of these instruments have been developed for patients with patella fractures or have been validated adequately for use in patients with patella fractures. Furthermore, the minimal clinical important difference among these instruments is unknown for patients with patella fractures.
Aim: The study aimed to investigate the validity, reliability, and responsiveness and estimate the minimal clinically important difference of KOOS to adult patients with patella fractures.
Materials and Methods: The study design was a prospective cohort study including patients treated conservatively or surgically following a patella fracture (AO-34). The primary outcome measure was the KOOS. The KOOS was repeated at 14 days, 15 days, six weeks, and six and 12 months. Content validity was evaluated by patients ranking the relevance of the 42 items in the KOOS, test- retest reliability by an interclass correlation coefficient, and responsiveness by effect size end estimation of minimal clinically important difference (MCID) by the anchor-base method.
Results: Included were 38 patients with a mean age of 63.3 years (range 24 to 89) with 74 % female gender. Results showed an acceptable content validity of all the KOOS subscales. The test- retest reliability was high for all five subscales, with an interclass correlation coefficient ranging from 0.8-0.9. At the 12-month follow-up, responsiveness showed large effect sizes for all the KOOS subscales (> 0.9). The MCID of the KOOS subscales were Pain 8.7, Symptoms 8.1, ADL 9.3, Sport/Rec 10.3 and QOL 7.1.
Interpretation / Conclusion: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is a valid and useful patient- reported instrument to monitor the status/recovery of patients with patella fractures. The questionnaire showed acceptable content validity, high reliability, and high responsiveness.
1 Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark 2 Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark. 3 Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.
Background: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is one commonly used knee- specific patient-reported outcome instrument, among several others, to capture the patient- perceived outcomes following patella fractures. However, to the authors’ knowledge, none of these instruments have been developed for patients with patella fractures or have been validated adequately for use in patients with patella fractures. Furthermore, the minimal clinical important difference among these instruments is unknown for patients with patella fractures.
Aim: The study aimed to investigate the validity, reliability, and responsiveness and estimate the minimal clinically important difference of KOOS to adult patients with patella fractures.
Materials and Methods: The study design was a prospective cohort study including patients treated conservatively or surgically following a patella fracture (AO-34). The primary outcome measure was the KOOS. The KOOS was repeated at 14 days, 15 days, six weeks, and six and 12 months. Content validity was evaluated by patients ranking the relevance of the 42 items in the KOOS, test- retest reliability by an interclass correlation coefficient, and responsiveness by effect size end estimation of minimal clinically important difference (MCID) by the anchor-base method.
Results: Included were 38 patients with a mean age of 63.3 years (range 24 to 89) with 74 % female gender. Results showed an acceptable content validity of all the KOOS subscales. The test- retest reliability was high for all five subscales, with an interclass correlation coefficient ranging from 0.8-0.9. At the 12-month follow-up, responsiveness showed large effect sizes for all the KOOS subscales (> 0.9). The MCID of the KOOS subscales were Pain 8.7, Symptoms 8.1, ADL 9.3, Sport/Rec 10.3 and QOL 7.1.
Interpretation / Conclusion: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is a valid and useful patient- reported instrument to monitor the status/recovery of patients with patella fractures. The questionnaire showed acceptable content validity, high reliability, and high responsiveness.
Amakiri Ikechukwu1, Devon Brameier2, Taylor Ottesen1, Audrey Kobayashi1, Alexander Farid3, Daniel Gabriel3, Kishore Konar2, Angela Mercurio3, Tyler Warner3, Michael Weaver2, Arvind von Keudell2
1. Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA 2. Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA 3. Harvard Medical School, Boston, MA, USA
Background: Periprosthetic fractures around total hip arthroplasty implants are challenging injuries to manage and there remains controversy regarding the best treatment. The standard treatment for Vancouver B2 periprosthetic femur fractures (VB2 PPFs) is revision arthroplasty (RA). However, some studies suggest that it might be reasonable to perform open reduction and internal fixation (ORIF) in select patients.
Aim: This primary purpose of this study is to compare the clinical outcomes of patients with VB2 PPFs treated with either ORIF or RA.
Materials and Methods: A retrospective review of patients =18 years, with VB2 PPFs, as defined in the primary surgeon operative note, who were treated with either ORIF or RA at a large tertiary institution between January 1, 2005, and April 1, 2022. Exclusion: pathologic fractures, periprosthetic joint infection, or insufficient follow-up. In cases of ORIF, an attempt was made to achieve an anatomic reduction with compression, with cerclage wires. RA involved revision to a modular diaphyseal engaging press-fit stem.
Results: 98 patients underwent either ORIF or RA for VB2 PPFs. 26 patients underwent ORIF, while 72 patients received RA. Patient demographics between the ORIF and RA groups (Table 1) showed no significant differences in age (p=0.40), CCI (p=0.22), BMI (p=0.44), gender (p=0.52), and smoking status (p=0.43), race (p=0.21). ORIF was associated with a shorter median time from injury to surgery in the ORIF group (p=0.02), less estimated blood loss (p=0.004), and operative time (p=0.08). However, there was no difference in transfusion rates (p=0.74), volume transfused (p=0.43), or length of stay (p=0.38). Total complication rates were similar between the ORIF and RA groups (23.1% vs.18.1%, p=0.58). There were no significant differences in 30-day and 1-year mortality (3.9% vs. 4.2%, p=0.94; 11.5% vs. 8.3%, p=0.63) or readmission rate (26.9% vs. 19.4%, p=0.43) between the ORIF and RA groups.
Interpretation / Conclusion: ORIF showed benefits in shorter surgery and less blood loss, but no significant differences in mortality or complication rate compared to RA. Both strategies are viable for managing VB2 PPFs, with choice tailored to patient factors and surgeon expertise.
1. Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA 2. Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA 3. Harvard Medical School, Boston, MA, USA
Background: Periprosthetic fractures around total hip arthroplasty implants are challenging injuries to manage and there remains controversy regarding the best treatment. The standard treatment for Vancouver B2 periprosthetic femur fractures (VB2 PPFs) is revision arthroplasty (RA). However, some studies suggest that it might be reasonable to perform open reduction and internal fixation (ORIF) in select patients.
Aim: This primary purpose of this study is to compare the clinical outcomes of patients with VB2 PPFs treated with either ORIF or RA.
Materials and Methods: A retrospective review of patients =18 years, with VB2 PPFs, as defined in the primary surgeon operative note, who were treated with either ORIF or RA at a large tertiary institution between January 1, 2005, and April 1, 2022. Exclusion: pathologic fractures, periprosthetic joint infection, or insufficient follow-up. In cases of ORIF, an attempt was made to achieve an anatomic reduction with compression, with cerclage wires. RA involved revision to a modular diaphyseal engaging press-fit stem.
Results: 98 patients underwent either ORIF or RA for VB2 PPFs. 26 patients underwent ORIF, while 72 patients received RA. Patient demographics between the ORIF and RA groups (Table 1) showed no significant differences in age (p=0.40), CCI (p=0.22), BMI (p=0.44), gender (p=0.52), and smoking status (p=0.43), race (p=0.21). ORIF was associated with a shorter median time from injury to surgery in the ORIF group (p=0.02), less estimated blood loss (p=0.004), and operative time (p=0.08). However, there was no difference in transfusion rates (p=0.74), volume transfused (p=0.43), or length of stay (p=0.38). Total complication rates were similar between the ORIF and RA groups (23.1% vs.18.1%, p=0.58). There were no significant differences in 30-day and 1-year mortality (3.9% vs. 4.2%, p=0.94; 11.5% vs. 8.3%, p=0.63) or readmission rate (26.9% vs. 19.4%, p=0.43) between the ORIF and RA groups.
Interpretation / Conclusion: ORIF showed benefits in shorter surgery and less blood loss, but no significant differences in mortality or complication rate compared to RA. Both strategies are viable for managing VB2 PPFs, with choice tailored to patient factors and surgeon expertise.