Knee Fractures Research Articles

Substantial decrease in paediatric lower extremity fracture rates in German hospitals in 2017 compared with 2002: an epidemiological study

BackgroundThere are no recent studies on the frequency of paediatric lower extremity fractures in Germany. The aims of this study were to report fracture rates of paediatric lower extremity fractures treated in German hospitals in 2002 and 2017 and to detect changes over time as well as to evaluate the gender and age distribution for each fracture location.MethodsData from the German National Hospital Discharge Registry, which covers over 99% of all German hospitals, were used for this study. The absolute frequencies and incidence of lower extremity fractures as well as age at the time of fracture and gender were included in the data. The population was subdivided into four age groups: 0–4, 5–9, 10–14, and 15–19 years. The boy: girl ratio (BGR) for all fracture locations was calculated by dividing the absolute frequency of boys by that of girls. The fracture incidence in 2017 was compared with 2002 by calculating the incidence rate ratio (IRR).ResultsThe total number of fractures decreased by 39.9% from 2002 to 2017. The most common fracture locations in 2002 were femoral shaft, tibial shaft, distal tibia, and lateral and medial malleolus; the absolute number of all these fractures was lower in 2017 than in 2002 in all age groups. The incidence of hip and thigh fractures, knee and lower leg fractures, and foot fractures decreased by 39.0, 41.1, and 33.3%. Proximal tibial fractures increased both in absolute numbers and in incidence in the age groups 0–4, 10–14, and 15–19 years (IRR ≥ 1.1). The overall BGR was 2.3 in 2002 and 2.0 in 2017, indicating that the number of girls relative to that of boys who suffered a lower extremity fracture was higher in 2017 than in 2002. Furthermore, the BGR of all fracture locations increased with age in both years.ConclusionsThe number of paediatric lower extremity fractures treated in German hospitals in 2017 was significantly lower than that in 2002. However, the fracture frequency in girls decreased to a lesser extent than that in boys. The incidence of proximal tibial fractures increased.

Added value of color-coded virtual non-calcium dual-energy CT in the detection of acute knee fractures in non-radiology inexpert readers

PurposeTo evaluated the added value of dual-energy CT (DECT) virtual non-calcium (VNCa) protocol on conventional CT in the detection of acute knee fractures in non-radiology inexpert readers. MethodOne hundred fifty-six patients (mean age, 51.97 years; age range, 17–86 years) with knee trauma, who underwent DECT and MRI within 3 days between April 2017 and October 2018, were retrospectively analyzed. Three readers (intern, 1st-year general surgery resident, 1st-year emergency medicine resident) independently analyzed CT alone and then with the additional color-coded DECT VNCa for fractures. A board-certified radiologist, analyzed CT and MRI series to define the reference standard. Sensitivity, specificity, and AUC were compared between the two reading sessions. ResultsFifty-seven patients had acute fractures and 99 had no fractures. Thirteen of 57 fractures were nondisplaced. The additional use of VNCa images significantly increased the mean AUC (reader 1: 0.813 vs. 0.919; reader 2: 0.842 vs. 0.930; reader 3: 0.837 vs. 0.921; P < 0.05). When only nondisplaced fractures included, the mean AUC was more increased in the combined analysis of CT and DECT VNCa (reader 1: 0.521 vs. 0.916; reader 2: 0.542 vs. 0.926; reader 3: 0.575 vs. 0.926; P < .01). Sensitivity increased by 15 %–20 % in total fracture group and by 69 %–77 % in nondisplaced fracture group over that with CT alone when both CT and DECT VNCa were used. Specificity did not differ significantly. ConclusionsThe additional use of color-coded DECT VNCa protocol to conventional CT improved diagnostic performance in detecting acute knee fractures for inexperienced non-radiology readers.

Factores de riesgo en fractura periprotésica femoral tras artroplastia sustitutiva primaria de rodilla

Introduction and objectivesPeriprosthetic fractures after primary knee arthroplasty has great importance in our environment due to the increase in their incidence and to the challenge they pose to the surgeon. Multiple factors have been associated with its production. The objective of the study was to identify the risk factors that could influence the appearance of these fractures, which of them are all modifiable and generate a probability prediction model based on these factors. Material and methodsAnalytical, observational, retrospective, unpaired study of 38 cases of periprosthetic femoral knee fractures and 80 controls with knee prostheses. In total, 118 patients, 83 women and 35 men with a mean age of 72.49 years were included in the study. Sociodemographic data, medical history and drug consumption were collected, as well as those related to surgery. A univariate and bivariate analysis of the fracture determining factors was performed, using a logistic regression model to avoid confusion bias. ResultsOf all the factors studied according to the logistic regression model, it was obtained that female sex (OR = 7.6), dementia (OR = 5), motor/parkinson's alteration (OR = 19.3) and femoral overcut Previous (OR = 8.6) were factors associated with the increased risk of this type of fractures. ConclusionsThis work allows us to conclude that there are risk factors such as female sex, dementia and parkinson's that increase the probability of periprosthetic fracture that are inherent to the patient and are not modifiable. However, there is any other totally modifiable that can be avoided by being demanding and thorough in the surgical technique, such as the anterior femoral overcut.

Risk Factors for Wound Complications After Periprosthetic Fractures.

The number of hip and knee arthroplasties performed annually continues to rise. Revision rates are projected to increase by 137% to 601%, with periprosthetic fractures to be among the leading cause of revision. Wound complications following surgical treatment of periprosthetic fractures are a major source of patient morbidity and health care costs. This study evaluated risk factors for wound healing complications in patients undergoing surgical management of periprosthetic fractures around the hip and knee. This was a retrospective analysis of 67 consecutive lower-extremity periprosthetic hip and knee fracture surgeries. Descriptive data, comorbidities, dressing type, and rates of wound complications treated nonoperatively and operatively were collected. Logistic regression analysis was performed to calculate odds ratios (ORs) of having a wound complication. There was an overall wound complication rate of 22%; the majority of these complications (16%) were treated operatively. On multivariate analysis, prior bariatric surgery (OR, 12.02; 95% confidence interval [CI], 1.24-116.71; P=.03), peripheral vascular disease (OR, 6.84; 95% CI, 1.32-35.39; P=.02), and pulmonary disease (OR, 11.23; 95% CI, 1.85-68.31; P=.01) were all associated with an increased risk of developing a wound complication. Closed-incision negative-pressure therapy was associated with a decreased risk of developing a wound complication (OR, 0.04; 95% CI, 0.00-0.49, P=.01). Surgery to treat hip and knee periprosthetic fractures is associated with a high rate of wound complications. History of bariatric surgery, peripheral vascular disease, and pulmonary disease are all associated with an increased risk of developing a wound complication. Future payment models should reflect this elevated level of complications and risk. [Orthopedics. 2020;43(4):e258-e262.].

Treatment of Periarticular Fractures of the Knee Using the Less Invasive Stabilization System: A Retrospective Clinical Trial.

IntroductionPeriarticular fractures of the knee in adults are generally treated with internal fixation. The Less Invasive Stabilization System (LISS) plate, developed by Arbeitsgemeinschaft Osteosynthesefragen (AO)/Association for the Study of Internal Fixation (ASIF) in the late 1990s, allows reduction and biological fixation through smaller incisions without violating periosteal blood supply. It offers several advantages for the treatment of complex periarticular fractures of the knee. In this study, we have aimed to report the results of a single series of these fractures.Materials and methodsForty-eight patients with AO type 33 and AO type 41 periarticular knee fractures who were operated between 2009 and 2014 at a single institution were included in this retrospective study. Patient demographics, fracture epidemiology, intraarticular extension, concomitant injuries, American Society of Anesthesiologists (ASA) score, time to union, the average time from admission to surgery, and the mean time from operation to patient discharge were noted. The effect of patient and fracture-related factors on length of hospital stay were evaluated.ResultsThe mean follow-up time was 23.7 (12-48) months. The average time from admission till surgery and from surgery till discharge was 10.2 (1-39) and 9.7 (2-35) days, respectively. The average time for union was 6.8 months. Femur fractures healed in mean 6.6 months whereas tibia fractures took 7.1 months to heal. Time from admission to surgery and postoperative hospital stay was longer in patients with higher ASA scores (p<0.01) and open fractures (p<0.001). Patients’ body mass index (BMI) and intraarticular extension of the fracture did not cause an increase in either preoperative or postoperative hospital stay (p>0.05). The presence of concomitant major injuries caused a delay in operation (p<0.05), whereas postoperative hospital stay was not different (p>0.05).ConclusionLISS plating provides good stability through a small incision, permits biological fracture healing, may be used in multifragmentary fractures and has low complication rates. It is a good alternative for the treatment of periarticular fractures of the knee.

Management of periprosthetic fractures of knee arthroplasty with revision surgery

ObjectiveAs periprosthetic knee fractures are becoming common with the increase in incidence of primary and revision total knee arthroplasty, their management and treatment have become important. The current study aims to evaluate the revision knee arthroplasty carried out due to the failure of primary treatment of periprosthetic femoral fractures. MethodsThe study was conducted from May 2012 to September 2019 at Orthopedics department of Xinjiang Medical University; out of 21 patients 11 were women and 10 men aged 44 to 80 (mean, 70.76 ± 8.31) years who underwent revision surgery for periprosthetic fractures of 19 distal femur, 1 patellar, and 1 proximal tibial fracture. Nineteen cases had definite trauma history leading to periprosthetic fracture, and 2 cases had fracture during post-operative functional exercise. All patients had revision surgery with extended stems with either constrained or limited condylar knee prosthesis. ResultsThe duration of follow-up averaged 4.3 years. The Hospital for Special Surgery (HSS) knee score before fracture averaged 91 + 7.01 points (89–95 points) and 85.5 + 6.18 points (81–90 points) at the last follow-up. The average range of motion of knee joint before fracture was 115.7 [+7.6] (110 [~126]), and 101.3 [+9.8] (85 [~115]) at the last follow-up. There was no significant statistical difference. No complications such as infection, component loosening or nonunion. 2 patients had lower extremity vein thrombosis. ConclusionRevision surgery of the knee for the periprosthetic fractures with proper prosthetic selection can attain good outcomes after primary total knee arthroplasty. Reasonable and correct procedure is the main principle for a successful operation. The benefits and applicability of revision TKA is the reconstructive solution for the issues of prosthetic knee fractures, is highly recommended.

Five-Year Risk of Conversion to Total Knee Arthroplasty After Operatively Treated Periarticular Knee Fractures in Patients Over 40 Years of Age

BackgroundPeriarticular knee fractures present a significant challenge to minimize post-traumatic osteoarthritis. The purpose of this study is to compare the rates of conversion to total knee arthroplasty (TKA) for different periarticular knee fractures, investigate the rate of knee injections as a more rapid assessment of knee symptoms, and identify risk factors that lead to conversion to TKA following periarticular fractures. MethodsA comprehensive retrospective review of the Humana administrative claims database was performed. A total of 2813 patients greater than 40 years of age with diagnosis code for tibial plateau fracture or distal femur fracture linked to a Current Procedural Terminology code of open reduction internal fixation between 2007 and 2011 were evaluated. The rates of TKA and knee injections within 5 years were compared. Cox proportional hazards model was used to evaluate risk factors for conversion. ResultsOf 2813 periarticular fractures, the 5-year rate of conversion to TKA was 3.3%. The rate of conversion for tibial plateau fractures was significantly higher at 4.5% compared to 2.3% for distal femur fractures (P = .001). Tibial plateau fracture, obesity, and female gender were risk factors found to portend an increased risk of conversion to TKA with hazard ratios of 1.77, 1.69, and 1.88, respectively. The overall rate of knee injections was 12.8% with an average time to injection of 18.2 months after open reduction internal fixation. ConclusionThe rate of conversion to TKA for periarticular knee fractures overall was 3.3%, while the rate of knee injections within 5 years of surgery was 12.8%, suggesting a not insignificant minority of patients require treatment for symptomatic knee pain. Level of EvidenceTherapeutic Level III.

Diagnostic accuracy of the Ottawa Knee Rule in adult acute knee injuries: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to evaluate the current evidence on the diagnostic accuracy of the Ottawa Knee Rule (OKR) for acute knee injuries in adults. A literature search of Embase (Elsevier), MEDLINE (U.S. National Library of Medicine), PubMed and Scopus databases (1995 to date; English language) was performed and the relevant references were assessed. Original articles documenting OKR use by emergency physicians to assess adult acute knee injuries were included. Study methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Results of eligible studies were pooled using random effects or fixed effects modelling to calculate the diagnostic performance of the OKR. The Higgins I2 test and Begg's association test were performed to assess between-study heterogeneity and publication bias respectively, with Spearman's correlation test for threshold effect. Eight studies, including 7385 patients, were enrolled and pooled using the random effects model. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.99 (95% CI, 0.97 to 1.00), 0.49 (95% CI, 0.47 to 0.51), 0.07 (95% CI, 0.02 to 0.24), 1.86 (95% CI, 1.72 to 2.01) and 25.10 (95% CI, 7.18 to 87.70) respectively. Based on the QUADAS-2 criteria, most studies presented low risk of bias and concern regarding applicability. Application of the OKR can rule out knee fracture and thus avoid unnecessary radiography. These results also translate to improved efficiency, lower medical costs and reduced waiting times. • The Ottawa Knee Rule helps clinicians to rule out fracture in adults with an acute knee injury. • The rule allows a reduction in radiography requests, patient waiting time in the emergency department and healthcare costs.

Analysis of mortality after surgical treatment of periprosthetic distal femur fractures

IntroductionThe incidence of periprosthetic fractures of the knee is increasing due to the increase in the number of total knee arthroplasties performed, together with population aging. We found few studies that analyze mortality in our setting after surgery. Our objective was to evaluate mortality and survival after surgical treatment of periprosthetic fractures of the distal femur in our environment. Material and methodWe conducted a retrospective observational study of a consecutive series of 97 patients surgically treated in our centre for periprosthetic knee fracture between 2007 and 2015, with a minimum follow-up of 12 months. Diverse sociodemographic, clinical and surgical variables were analyzed. A consultation was made to the National Death Index of the Ministry of Health for the analysis of mortality and survival was analyzed using the Kaplan-Meier method. ResultsWe reviewed a total of 97 patients with an average age of 75 years, of which 86 were women and 11 were men. Of the patients, 50.5% of patients had some comorbidity. The average delay until the intervention was 3.1 days. With respect to the treatment, 45 patients were operated by osteosynthesis with plate (49.5%), 40 with intramedullary nail (41.2%) and 9 with revision of the arthroplasty (9.3%). A total of 30 deaths were recorded during the follow-up, with cumulative mortality in the first year, at 3 and at 10 years of 7.2%, 17.5% and 30.9%, respectively, progressively increasing in people over 75 years. There was no significant difference in mortality rates with the osteosynthesis method. The main complication was pseudoarthrosis (6.2%). ConclusionsPeriprosthetic knee fractures are associated with high rates of complications and mortality. The patient's age and the lesion itself are non-modifiable factors that can influence mortality after surgery, while other variables such as the type of intervention or surgical delay did not show differences in mortality rates in our study.

Análisis de la mortalidad tras el tratamiento quirúrgico de las fracturas periprotésicas de fémur distal

IntroductionThe incidence of periprosthetic fractures of the knee is increasing due to the increase in the number of total knee arthroplasties performed, together with population aging. We found few studies that analyze mortality in our setting after surgery. Our objective was to evaluate mortality and survival after surgical treatment of periprosthetic fractures of the distal femur in our environment. Material and methodWe conducted a retrospective observational study of a consecutive series of 97 patients surgically treated in our centre for periprosthetic knee fracture between 2007-2015, with a minimum follow-up of 12months. Diverse sociodemographic, clinical and surgical variables were analyzed. A consultation was made to the National Death Index of the Ministry of Health for the analysis of mortality and survival was analyzed using the Kaplan-Meier method. ResultsWe reviewed a total of 97 patients with an average age of 75years, of which 86 were women and 11 were men. Of the patients, 50.5% of patients had some comorbidity. The average delay until the intervention was 3.1days. With respect to the treatment, 45 patients were operated by osteosynthesis with plate (49.5%), 40 with intramedullary nail (41.2%) and 9 with revision of the arthroplasty (9.3%). A total of 30 deaths were recorded during the follow-up, with cumulative mortality in the first year, at 3 and at 10 years of 7.2%, 17.5% and 30.9%, respectively, progressively increasing in people over 75years. There was no significant difference in mortality rates with the osteosynthesis method. The main complication was pseudoarthrosis (6.2%). ConclusionsPeriprosthetic knee fractures are associated with high rates of complications and mortality. The patient's age and the lesion itself are non-modifiable factors that can influence mortality after surgery, while other variables such as the type of intervention or surgical delay did not show differences in mortality rates in our study.

Corrigendum to “Open Periprosthetic Knee Fracture: A Case Report and Review of the Literature”

[This corrects the article DOI: 10.1177/2151459320939547.].

Open Periprosthetic Knee Fracture: A Case Report and Review of the Literature.

Introduction:With the increase in knee and hip implants, these periprosthetic fractures will become more common especially as the population ages. Open periprosthetic fractures are rare and severe injuries and are more likely to be seen in high-energy injuries. They present challenges to the treating physician due to soft tissue damage, contamination of the existing implants, and the effects of polytrauma in the geriatric patient.Methods: Case review report and review of literature. ResultsA 72-year-old woman was involved in a motor vehicle collision with multiple injuries including an open periprosthetic tibia and femur fracture. This was treated with initial washout and removal of loose tibial component with placement of a cement spacer. The knee was treated with staged revision using a protocol like that used after prosthetic joint infection. After complete soft tissue healing, the patient underwent successful revision with a megaprosthesis. The literature on open periprosthetic fractures is reviewed.Discussion and Conclusion:Open periprosthetic fractures present multiple challenges to the orthopedic surgeon. In the presences of poly trauma and soft tissue injury, we present an approach using staged surgery like that used for prosthetic joint infection.

Knee Mega-Prosthesis in the Management of Complex Knee Fracture of the Elderly a Case Series and Review of the Literature

The management of complicated distal femur fractures (DFF) of the elderly continues to pose a challenge. Knee mega-prosthesis are mostly used for Total knee arthroplasty revision and tumor resection surgery but they can be used for the treatment of complex knee fractures. The purpose of the present study is to examine the short- to mid- term outcomes of their use for complex DFF of the elderly. We retrospectively identified 4 patients with DFF AO33C3 on osteoporotic bone treated by total knee arthroplasty from September 2015 to October 2019. The average age at the time of the surgery was 79,5 years (range, 69 to 95 years). All patients were females and underwent a total knee replacement by one senior surgeon, with the OSS TM Orthopaedic Salvage System (Zimmer Biomet, Warsaw, Indiana, USA). Outcome measures included clinical outcome scores, radiological analyses, reoperation rate and complications. At an average follow-up of 2,3 years (range, 0,6 to 4,2 years), the average Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) was 17,25 (range, 7 to 37), the average Oxford knee score was 35,25 (range, 25 to 41) and the average pain Numerical Rating Scale (NRS) was 0,5 (range, 0 to 1). 3 Patients had postoperative anemia but no implant related complications has been reported. Complex DFF of the elderly treated with mega knee arthroplasty exhibit good clinical outcomes scores. The patients should be selected carefully as the complication rate found in the literature remains high.

Knee Fracture Increases TKA Risk After Initial Fracture Treatment and Throughout Life.

Knee fractures may lead to post-traumatic knee osteoarthritis and subsequent TKA in some patients. However, absolute risk estimates and risk factors for TKA in patients with knee fractures compared with those of the general population remain largely unknown. Such knowledge would help establish the treatment burden and direct patient counseling after a knee fracture is sustained. (1) What is the short-term risk of TKA after knee fracture? (2) What is the long-term risk of TKA after knee fracture? (3) What are the risk factors for TKA in patients with knee fractures? A nationwide 20-year, matched-case comparison cohort study of prospectively collected data from the Danish National Patient Registry included all patients at least 15 years old with International Classification of Diseases, 10th revision codes DS724, DS820, or DS821 (knee fractures) on the date their knee fracture was registered. Each patient with a knee fracture was matched (by sex and age) to five people without knee fractures from the general Danish population on the date the knee fracture patient's knee fracture was registered (population controls). Patients with knee fractures and people in the population control group were followed from the date the knee fracture patient's knee fracture was registered to the date of TKA, amputation, knee fusion, emigration, death, or end of follow-up in April 2018. TKA risks for patients with knee fractures versus those for population controls and TKA risk factors in patients with knee fractures were estimated using hazard ratios (HRs) with 95% CIs. A total of 48,791 patients with knee fractures (median age 58 years [interquartile range 41-73]; 58% were female) were matched to 263,593 people in the population control group. The HR for TKA in patients with knee fractures compared with population controls was 3.74 (95% CI 3.44 to 4.07; p < 0.01) in the first 3 years after knee fracture. Among knee fracture patients, the risk of undergoing TKA was 2% (967 of 48,791) compared with 0.5% (1280 of 263,593) of people in the population control group. After the first 3 years, the HR was 1.59 (95% CI 1.46 to 1.71) and the number of patients with knee fractures with TKA events divided by the number at risk was 2% (849 of 36,272), compared with 1% (2395 of 180,418) of population controls. During the 20-year study period, 4% of patients with knee fractures underwent TKA compared with 1% of population controls. Risk factors for TKA in patients with knee fractures were: primary knee osteoarthritis (OA) versus no primary knee OA (HR 9.57 [95% CI 5.39 to 16.98]), surgical treatment with external fixation versus open reduction and internal fixation and reduction only (HR 1.92 [95 % CI 1.01 to 3.66]), proximal tibia fracture versus patellar fracture (HR 1.75 [95 % CI 1.30 to 2.36]), and distal femur fracture versus patellar fracture (HR 1.68 [95 % CI 1.08 to 2.64]). Surgical treatment of knee fractures was also a risk factor for TKA. The HRs for TKA in patients with knee fractures who were surgically treated versus those who were treated non-surgically were 2.05 (95% CI 1.83 to 2.30) in the first 5 years after knee fracture and 1.19 (95% CI 1.01 to 1.41) after 5 years. Patients with knee fractures have a 3.7 times greater risk of TKA in the first 3 years after knee fracture, and the risk remains 1.6 times greater after 3 years and throughout their lifetimes. Primary knee OA, surgical treatment of knee fractures, external fixation, proximal tibia fractures, and distal femur fractures are TKA risk factors. These risk estimates and risk factors highlight the treatment burden of knee fractures, building a foundation for future studies to further counsel patients on their risk of undergoing TKA based on patient-, fracture-, and treatment-specific factors. Level III, prognostic study.

The effective dose due to scattered radiation at patients during primary osteosynthesis; a multicenter prospective observational study

ObjectivesDuring osteosynthesis of a fracture patients are exposed to the primary radiation of an X-ray image and scattered (secondary) radiation. The primary objective was to measure the amount of scattered radiation at the thyroid, breast tissue, and gonads of patients undergoing primary osteosynthesis of acute fractures. The secondary objective was to calculate the effective dose caused by scattered radiation. MethodsIn this multicenter prospective observational case series patients undergoing a primary osteosynthesis of an acute fracture of hand/wrist, shoulder, ankle, knee, or hip were included. Three dosimeters were attached to the patient at the level of the thyroid, breast and gonads. Scattered radiation doses were corrected for the average background radiation per hospital per day. ResultsA total of 205 patients were included between March 6, 2017 and June 18, 2018; 49 (24%) had a hand/wrist fracture, 37 (18%) a shoulder fracture, 47 (23%) an ankle fracture, 35 (17%) a knee fracture, and 37 (18%) a hip fracture. In 32–39% of all patients undergoing primary osteosynthesis effective scattered doses was detected. The highest measured median effective dose was 60.43 µSv (P25–P75 33.84–100.76) at the gonads during hip osteosynthesis. ConclusionsThe results of this study show that scattered radiation is detectable in a third of patients undergoing an osteosynthesis. However, both effective doses due to direct radiation and scattered radiation are low. Advances in knowledgeThis is the first study that presents that no radiation protection for patients undergoing an osteosynthesis is necessary.

20-year trends of distal femoral, patellar, and proximal tibial fractures: a Danish nationwide cohort study of 60,823 patients

Background and purpose — Knee fracture treatment burden remains unknown, impeding proper use of hospital resources. We examined 20-year trends in incidence rates (IRs) and patient-, fracture-, and treatment-related characteristics of knee fracture patients.Patients and methods — This nationwide cohort study of prospectively collected data including patients with distal femoral, patellar, and proximal tibial fractures from the Danish National Patient Registry during 1998–2017, assesses IRs of knee fractures (per 105 inhabitants) as well as patient-, fracture-, and treatment-related characteristics of knee fracture patients.Results — During 1998–2017, 60,823 patients (median age 55; 57% female) sustained 74,106 knee fractures. 74% of the study population had a Charlson Comorbidity Index (CCI) of 0 and 18% a CCI of ≥ 2. 51% were proximal tibial fractures, 31% patellar fractures, and 18% distal femoral fractures. At the time of knee fracture, 20% patients had concomitant near-knee fractures (femur/tibia/fibula shaft/hip/ankle), 13% concomitant fractures (pelvic/spine/thorax/upper extremities), 5% osteoporosis, and 4% primary knee osteoarthritis. Over 1/3 knee fractures were surgically treated and of these 86% were open-reduction internal fixations, 9% external fixations, and 5% knee arthroplasties. The most common surgery type was proximal tibia plating (n = 4,868; 60% female). Knee fracture IR increased 12% to 70, females aged > 51 had the highest knee fracture IR, proximal tibial fracture had the highest knee fracture type IR (32) and surgically treated knee fracture IR increased 35% to 23.Interpretation — Knee fracture IRs, especially of surgically treated knee fractures, are increasing and proximal tibial fracture has the highest knee fracture type IR. Females aged > 51 and patients with comorbidity are associated with knee fracture, proximal tibial fracture, proximal tibial fracture surgery, and posttraumatic knee arthroplasty.

Opioid use, postoperative complications, and implant survival after unicompartmental versus total knee replacement: a population-based network study.

There is uncertainty around whether to use unicompartmental knee replacement (UKR) or total knee replacement (TKR) for individuals with osteoarthritis confined to a single compartment of the knee. We aimed to emulate the design of the Total or Partial Knee Arthroplasty Trial (TOPKAT) using routinely collected data to assess whether the efficacy results reported in the trial translate into effectiveness in routine practice, and to assess comparative safety. We did a population-based network study using data from four US and one UK health-care database, part of the Observational Health Data Sciences and Informatics network. The inclusion criteria were the same as those for TOPKAT; briefly, we identified patients aged at least 40 years with osteoarthritis who had undergone UKR or TKR and who had available data for at least one year prior to surgery. Patients were excluded if they had evidence of previous knee arthroplasty, knee fracture, knee surgery (except diagnostic), rheumatoid arthritis, infammatory arthropathies, or septic arthritis. Opioid use from 91-365 days after surgery, as a proxy for persistent pain, was assessed for all participants in all databases. Postoperative complications (ie, venous thromboembolism, infection, readmission, and mortality) were assessed over the 60 days after surgery and implant survival (as measured by revision procedures) was assessed over the 5 years after surgery. Outcomes were assessed in all databases, except for readmission, which was assessed in three of the databases, and mortality, which was assessed in two of the databases. Propensity score matched Cox proportional hazards models were fitted for each outcome. Calibrated hazard ratios (cHRs) were generated for each database to account for observed differences in control outcomes, and cHRs were then combined using meta-analysis. 33 867 individuals who received UKR and 557 831 individuals who received TKR between Jan 1, 2005, and April 30, 2018, were eligible for matching. 32 379 with UKR and 250 377 with TKR were propensity score matched and informed the analyses. UKR was associated with a reduced risk of postoperative opioid use (cHR from meta-analysis 0·81, 95% CI 0·73-0·90) and a reduced risk of venous thromboembolism (0·62, 0·36-0·95), whereas no difference was seen for infection (0·85, 0·51-1·37) and readmission (0·79, 0·47-1·25). Evidence was insufficient to conclude whether there was a reduction in risk of mortality. UKR was also associated with an increased risk of revision (1·64, 1·40-1·94). UKR was associated with a reduced risk of postoperative opioid use compared with TKR, which might indicate a reduced risk of persistent pain after surgery. UKR was associated with a lower risk of venous thromboembolism but an increased risk of revision compared with TKR. These findings can help to inform shared decision making for individuals eligible for knee replacement surgery. EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative (2) Joint Undertaking (EHDEN).

Association of Physical Activity and Fracture Risk Among Postmenopausal Women

Physical activity is inversely associated with hip fracture risk in older women. However, the association of physical activity with fracture at other sites and the role of sedentary behavior remain unclear. To assess the associations of physical activity and sedentary behavior with fracture incidence among postmenopausal women. The Women's Health Initiative prospective cohort study enrolled 77 206 postmenopausal women aged 50 to 79 years between October 1993 and December 1998 at 40 US clinical centers. Participants were observed for outcomes through September 2015, with data analysis conducted from June 2017 to August 2019. Self-reported physical activity and sedentary time. Hazard ratios (HRs) and 95% CIs for total and site-specific fracture incidence. During a mean (SD) follow-up period of 14.0 (5.2) years among 77 206 women (mean [SD] age, 63.4 [7.3] years; 66 072 [85.6%] white), 25 516 (33.1%) reported a first incident fracture. Total physical activity was inversely associated with the multivariable-adjusted risk of hip fracture (>17.7 metabolic equivalent [MET] h/wk vs none: HR, 0.82; 95% CI, 0.72-0.95; P for trend < .001). Inverse associations with hip fracture were also observed for walking (>7.5 MET h/wk vs none: HR, 0.88; 95% CI, 0.78-0.98; P for trend = .01), mild activity (HR, 0.82; 95% CI, 0.73-0.93; P for trend = .003), moderate to vigorous activity (HR, 0.88; 95% CI, 0.81-0.96; P for trend = .002), and yard work (HR, 0.90; 95% CI, 0.82-0.99; P for trend = .04). Total activity was positively associated with knee fracture (>17.7 MET h/wk vs none: HR, 1.26; 95% CI, 1.05-1.50; P for trend = .08). Mild activity was associated with lower risks of clinical vertebral fracture (HR, 0.87; 95% CI, 0.78-0.96; P for trend = .006) and total fractures (HR, 0.91; 95% CI, 0.87-0.94; P for trend < .001). Moderate to vigorous activity was positively associated with wrist or forearm fracture (HR, 1.09; 95% CI, 1.03-1.15; P for trend = .004). After controlling for covariates and total physical activity, sedentary time was positively associated with total fracture risk (>9.5 h/d vs <6.5 h/d: HR, 1.04; 95% CI, 1.01-1.07; P for trend = .01). When analyzed jointly, higher total activity mitigated some of the total fracture risk associated with sedentary behavior. Analysis of time-varying exposures resulted in somewhat stronger associations for total physical activity, whereas those for sedentary time were materially unchanged. In older ambulatory women, higher total physical activity was associated with lower total and hip fracture risk but higher knee fracture risk. Mild activity and walking were associated with lower hip fracture risk, a finding with important public health implications because these activities are common in older adults. The positive association between sedentary time and total fracture risk requires further investigation.

Ipsilateral Hip Dislocation with Knee Fracture Dislocation: A Rare Combination

Ipsilateral Hip Dislocation with Knee Fracture Dislocation: A Rare Combination

Risk of Pulmonary Embolism More Than 6 Weeks After Surgery Among Cancer-Free Middle-aged Patients

The risk of postoperative pulmonary embolism has been reported to be highest during the first 5 weeks after surgery. However, how long the excess risk of postoperative pulmonary embolism persists remains unknown. To assess the duration and magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery. Case-crossover analysis to compute the respective risks of pulmonary embolism after 6 types of surgery using data from a French national inpatient database, which covers a total of 203 million inpatient stays over an 8-year period between 2007 and 2014. Participants were cancer-free middle-aged adult patients (aged 45 to 64) with a diagnosis of a first pulmonary embolism. Hospital admission for surgery. Surgical procedures were classified into 6 types: (1) vascular surgery, (2) gynecological surgery, (3) gastrointestinal surgery, (4) hip or knee replacement, (5) fractures, and (6) other orthopedic operations. Diagnosis of a first pulmonary embolism. A total of 60 703 patients were included (35 766 [58.9%] male; mean [SD] age, 56.6 [6.0] years). The risk of postoperative pulmonary embolism was elevated for at least 12 weeks after all types of surgery and was highest during the immediate postoperative period (1 to 6 weeks). The excess risk of postoperative pulmonary embolism ranged from odds ratio (OR), 5.24 (95% CI, 3.91-7.01) for vascular surgery to OR, 8.34 (95% CI, 6.07-11.45) for surgery for fractures. The risk remained elevated from 7 to 12 weeks, with the OR ranging from 2.26 (95% CI, 1.81-2.82) for gastrointestinal operations to 4.23 (95% CI, 3.01-5.92) for surgery for fractures. The risk was not clinically significant beyond 18 weeks postsurgery for all types of procedures. The risk of postoperative pulmonary embolism is elevated beyond 6 weeks postsurgery regardless of the type of procedure. The persistence of this excess risk suggests that further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define the optimal duration of treatment with regard to both the thrombotic and bleeding risks.