Introduction: Hemiarthroplasty (HA) and total hip replacement (THR) are standard surgical procedures in the treatment of elderly patients with displaced fractures of the femoral neck with a predictable outcome regarding hip function and health-related quality of life (HRQoL). However, dislocation of the prosthesis remains a significant problem in this patient cohort with a reported incidence of 2–16% after HA and 2–22% after THR. Even though a dislocation is a relatively common, severe, and expensive complication, there are no previous prospective studies reporting the HRQoL for patients suffering prosthetic dislocations.

Patients and Methods: During the year 2003, 2213 consecutive patients with an acute hip fracture admitted to any of the four major university hospitals in Stockholm County were included in a prospective cohort study. From that cohort, 319 consecutive patients with a displaced femoral neck fracture (Garden III and IV) treated with a primary HA or THR were included. Patients with severe cognitive dysfunction and/or dementia were not included. HRQoL was assessed with the EQ-5D. The EQ-5D index score during the last week before the fracture and at 4 and 12 months after surgery was calculated. All dislocations and associated reoperations were recorded. Patients were divided into three groups: no dislocation (0), only one dislocation (1), and those suffering recurrent dislocations (≥2) during the 12-month follow-up. We used a mixed linear model to perform a multivariable analysis of the influence of dislocations on HRQoL measured as the EQ-5D index score over time. Six independent factors were analyzed: dislocation, time, type of prosthesis (THR, cemented HA, and uncemented HA), ASA class, gender, and age.

Results: A prosthetic dislocation occurred in 21 of the 319 patients (6.6%). All first and second dislocations occurred before the 4-month follow-up. Patients suffering recurrent dislocations had a significantly lower EQ-5D index score compared to those without dislocations at both 4 and 12 months. Patients suffering only one dislocation had a temporary decrease in the EQ-5D index score at 4 months while their EQ-5D index score at 12 months was equal to that of patients without dislocations. The adjusted multivariable analysis indicated that dislocation, type of prosthesis and time were significantly related to the quality of life.

Discussion: In patients with fractures of the femoral neck treated with a primary hip arthroplasty recurrent dislocations of the prosthesis had a pronounced negative influence on the patients’ HRQoL, while in patients with only one dislocation, the HRQoL seems to recover during the first year after surgery.

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome.

Setting: Six major hospitals in Stockholm County.

Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome.

Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures.

Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon.

Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA).

Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively.

Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative.

Background: Total hip arthroplasty (THR) is a commonly performed procedure to treat displaced fractures of the femoral neck, either as a primary procedure, or as a secondary procedure after failed healing of internal fixation. Dislocation of the prosthesis remains as a problem, and controversies still exist regarding the optimal surgical approach and its influence on stability of the THR. The main issue is whether to use an anterolateral or a posterolateral surgical approach. Repair of the posterior soft tissue structures when performing a posterolateral approach has been proposed to increase the stability. Other factors such as age, gender, indication for surgery (primary, secondary), caput size and the experience of the surgeon may also influence the stability, but are not well documented.

Material and Methods: Between January 1 1999, and December 31 2005, 532 consecutive THR’s in 523 patients were performed at our institution as a primary, or a secondary, procedure after fracture of the femoral neck. The patients have been followed with a prospective 6 week questionnaire, and after that via the clinics journal database. Finally, thanks to the Swedish personal identification number, a search has been done in a national registry by the Swedish National Board of Health and Welfare. For all patients, all dislocations and related reoperations until December 31 2006, or death, were registered and analyzed. Logistic regression analyse was performed in order to evaluate factors associated with prosthetic dislocation. Age, gender, indication for surgery, the surgeon’s experience, caput size and surgical approach were tested as independent variables in the model.

Results: Dislocation of the THR occurred in 27 patients. In the multivariate regression analyze the posterolateral surgical approach performed without posterior repair was associated with a significant higher risk of dislocation compared with the anterolateral approach (OR 4.7, 95% CI 1.1–19.6). The 28 mm caput size was associated with a significant lower risk of dislocation compared with the 22 mm (OR 0.3, 95% CI 0.1–0.99). There was a strong, but not significant, trend of higher risk for dislocation with a posterolateral approach performed with posterior repair compared with the anterolateral approach (OR 3.3, 95% CI 0.9–11.4). Age, gender, indication for surgery or the experience of the surgeon did not affect the risk for dislocation.

Interpretations: We recommend the anterolateral surgical approach and 28 mm caput size for THR after femoral neck fracture.

Several studies have evaluated the association between timing of hip fracture surgery and mortality in elderly patients. The evaluation of functional outcome is lacking.

We studied the effect of delayed surgery on the patient’s ability to return to independent living, the incidence of pressure sore and total length of hospital stay. Days of hospital stay included the post-operative period and the rehabilitation admission in the first 4 months following the operation.

Patients older than 50 years of age, admitted to two major hospitals in Stockholm during one year were included in the study (n = 853). To eliminate the effect of time interval between injury and admission, all patients who arrived to the hospital later than 24 hours of the injury (n=75) were excluded. Patients with pathological fracture (n = 30) were also excluded. The time intervals between hospital admission and the operation were evaluated against the patient post-operative independent living at 4 months follow up.

We divided the patients into two groups depending on delay to surgery. We performed a comparison of those patients who operated within 24 hours with those who hade been operated more than 24 hours after the admission. Moreover we repeated the analysis using 36 and 48 hours cut-off points.

After adjustment for age, ASA, walking ability, living with some one, gender and reason for delay, the late operated groups had a significantly decreased OR for return to independent living at 36 and 48 hours cutoff points (OR 0.5 respectively 0.3) but not at 24 hour cut-off point. The incidence of pressure sore in the late operated groups was significantly increased at all 3 cutoff points after adjustment for age, ASA, walking ability, dementia, and duration of surgery (OR 2.2, 3.4 and 4.2 respectively).

The median length of hospital stay was significantly increased in the late operated groups (14 versus 18 days at 24 hours, 15 versus 19 days at 36 hours, and 15 versus 21 days at 48 hours cut-off point). Linear regression analysis with adjustment for age, ASA, walking ability, dementia, gender and place of residence showed that there was a significant relationship between waiting time for operation (hours) and length of hospital stay (days) (B 0.148, P 0.002). Accordingly for every 6.75 hours delay in surgery, the total hospital stays increased by one day.

Our conclusion is that early operation of patients with hip fracture is associated with a significantly improved ability to return to independent living, a reduced incidence of decubitus ulcers and reduction in the length of hospital stay before the 4-month follow up.

Introduction: The treatment for the active and lucid elderly patient with a displaced femoral neck fracture is still controversial. Recent randomized controlled trials have shown that a primary total hip replacement (THR) is superior to internal fixation (IF) regarding the need for secondary surgery, hip function, and the health-related quality of life (HRQoL). Despite the good results with THR in this patient group, a vast majority of orthopaedic surgeons prefer hemiarthroplasty (HA) before THR. The aim of this study was to analyze the outcome regarding hip function and HRQoL after a displaced femoral neck fracture in a active and lucid elderly patient randomized to either a bipolar HA or THR.

Patients and Methods: 120 patients (101 females), mean age 81 (range 70 – 90), with an acute displaced femoral neck fracture (Garden III and IV) were randomized to bipolar HA or THR. Perioperative data, hip complications, general complications, hip function (Harris Hip Score, HHS) and HRQoL (EQ-5D) were assessed. The patients were summoned at 4 and 12 months.

Results: The duration of surgery was longer in the THR group, 102 versus 78 min, and the intraoperative blood loss was higher, 460 ml versus 320 ml. There were no differences between the groups regarding hip complications and general complications including mortality. There were no dislocations. Hip function (HHS score) was significantly better in the THR group at both follow-ups, p< 0.05 and < 0.001, respectively, with a trend towards an increasing difference with time. The HRQoL (EQ-5D index score) were in favor of the THR group although not statistically significant.

Discussion: The results of this study indicate that a THR gives better hip function compared to a bipolar HA already after one year without increasing the complication rate. There are good reasons to assume that this difference will increase with time. We recommend THR as the primary treatment for the active and lucid elderly patient with a displaced femoral neck fracture.

Introduction: Humeral shaft fractures account for 1–3% of all fractures. Little is known about additional epidemiological data on this specific fracture type. The aim of this study was to investigate the epidemiology of humeral shaft fractures in patients 16 years or older in Stockholm during the years 1998–99.

Patients and Methods: All patients 16 years or older with a humeral shaft fracture admitted to any of six major hospitals in the County of Stockholm during the two years 1998–99 were included in the study. A total of 401 fractures in 397 patients were found. Three hundred and sixty-one of the fractures were traumatic and were classified according to the Orthopaedic Trauma Association (OTA) classification system. The remaining 40 fractures were pathological (n=34) or peri-implant fractures (n=6). Open fractures were classified using the Gustilo classification system. Data regarding the injury mechanism, age, gender, side of the injury and occurrence of possible radial nerve injury were collected from the medical charts. The overall incidence and the age-specific incidence were calculated on the basis of data from Statistics Sweden.

Results: The incidence was 14.5 per 100 000 persons per year with a gradually increasing age-specific incidence from the fifth decade in both genders and reaching an incidence of almost 60 per 100 000 persons and year in the ninth decade. The majority of fractures were closed ones sustained after simple falls among elderly patients. The age distribution among females was characterised by a peak in the eighth decade while the age distribution among males was more even. Type A (simple) fractures were by far the most common and the majority of the fractures were located in the middle and proximal parts of the humeral shaft. The incidence of radial palsy was 8%. Fracture localisation in the middle and distal part of the shaft was associated with an increased risk for having radial nerve palsy. Only 2% of the fractures were open and 8% were pathological.

Discussion: These recent epidemiological data on humeral shaft fractures are representative of a society with a limited amount of high-energy trauma, including penetrating trauma, which probably reflects the situation in the majority of European countries. Our results can be used to facilitate the future treatment of patients with this particular fracture.

The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data, general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12 months.

The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to 131) (p < 0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p < 0.001), but there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group. Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods (p = 0.011 and p < 0.001, respectively). The health-related quality of life measure was in favour of the total hip replacement group but did not reach statistical significance (p = 0.818 at four months and p = 0.636 at 12 months).

These results indicate that a total hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report).

General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D_index score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001).

In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction.

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).

The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D_indexscore) was significant in both groups compared with that before the fracture (p < 0.005).

Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.

The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.

Fracture healing complications and reoperations after internal fixation (IF) of displaced femoral neck fractures are common in spite of an improved surgical technique. The complication rate in prospective studies with a two-year follow-up is 35–50%. The long-term outcome after a unipolar hip arthroplasty seems to be suboptimal for active patients and the outcome after a bipolar arthroplasty is insufficiently reported.

In a prospective study the fracture healing complications rate at two years in patients with displaced femoral neck fractures treated with IF was 36% compared with 7% in patients with undisplaced fractures. The quality of life (EQ-5D) of patients with uneventfully healed fractures at two years was lower in patients with primary displaced fractures than in patients with primary undisplaced fractures.

In a prospective randomised trial, patients with displaced femoral neck fractures were randomised to IF or total hip replacement (THR). IF resulted in more complications than THR, 36% versus 4%, and necessitated more reoperations, 42% versus 4%. Hip function and quality of life (EQ-5D) were generally better in the THR group.

The future treatment algorithms for elderly patients with displaced femoral neck fractures would benefit from being patient-related rather than diagnosisrelated. For an elderly, relatively healthy, lucid patient with a displaced femoral neck fracture THR yielded a better outcome than IF. The indications for unipolar- and bipolar arthroplasties need to be further evaluated in randomised trials with sufficient follow-up time.

The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery. We have studied 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck. They were randomly placed into two groups, treated either by internal fixation (IF) with two cannulated screws or total hip replacement (THR). None showed severe cognitive dysfunction, all were able to walk independently, and all lived in their own home. They were reviewed at four, 12 and 24 months after surgery. Outcome measurements included hip complications, revision surgery, hip function according to Charnley and the health-related quality of life (HRQoL) according to EuroQol (EQ-5D).

The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications (36% and 4%, respectively; p < 0.001), and the number of revision procedures (42% and 4%, p < 0.001). Hip function was significantly better in the THR group at all follow-up reviews regarding pain (p < 0.005), movement (p < 0.05 except at 4 months) and walking (p < 0.05). The reduction in HRQoL (EQ-5D _index score) was also significantly lower in the THR group than in the IF group, comparing the pre-fracture situation with that at all follow-up reviews (p < 0.05).

The results of our study strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck.