| 1. |
- Mohammad Ismail, Ahmad, 1993-
(författare)
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The Association Between Beta-Blocker Therapy and Mortality in Hip Fracture Patients
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Hip fractures have been a major concern within the healthcare systems for many years. National efforts have been done to improve the overall outcomes during the last decades. Despite this, the mortality rates one year after hip fracture surgery are as high as 27% and have remained high the past 15 years. Patients that suffer from hip fractures are often elderly and have several comorbidities. The orthopaedic trauma and subsequent emergency surgery impose an activation of the sympathetic nervous system mediated through the release of catecholamines. This causes a hyper-adrenergic state, which can be harmful if prolonged, or if the patient already has a strain caused by comorbidities forgoing the injury, especially on the cardiovascular system. This gave rise to the thought of blocking the adrenergic receptor activation in hip fracture patients as an effort to reduce the mortality rates.Papers I and II investigates the association between beta-blocker therapy and short-term mortality in hip fracture patients. In Paper I, (n=2443) patients operated in Orebro County between 2013 to 2017 were extracted from The National Quality Register for Hip Fractures (Rikshöft), to enable a more detailed review of the medical journals. The patients were divided into a betablocker cohort and a beta-blocker naive cohort. Results showed an 18% reduction in the risk of postoperative mortality within 90 days of surgery. In Paper II, all adults operated for traumatic hip fractures in Sweden between 2008 to 2017 were extracted from The National Quality Register for Hip Fractures and then cross-referenced with data from registers of The National Board of Health and Welfare. This resulted in a total of 134,915 patients eligible for analysis. The results demonstrated a 72% risk reduction in postoperative mortality within 30 days of surgery in the cohort with ongoing beta-blocker therapy.Paper III explored if the effect seen in Paper I-II remains up to one year using the same database as Paper II. The results demonstrated that the association between beta-blocker therapy and reduction in the risk of mortality,extending up to one year postoperatively, with the main effect seen during the first postoperative period.Paper IV investigates the interaction between the Revised Cardiac Risk Index and beta-blocker therapy related to 30-day post-operative mortality. This study concluded that all geriatric hip fracture patients could benefit from beta-blockers, but a more pronounced effect was seen in those with cardiac risk factors.
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| 2. |
- Lundqvist, Eva, 1985-
(författare)
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Distal radius fractures AO type C : A clinical and radiographic investigation
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The function of the hand is of substantial importance, and injuries have an impact on daily life. Distal radius fracture (DRF) is the most common fracture among adults. The annual incidence is 26 per 10,000 inhabitants, and the incidence is increasing because of an aging population. There has been a shift from conservative and other operative treatments, toward volar plate fixation to restore the anatomy and improve results. Operative treatment is often considered for displaced and unstable fractures. The optimal choice of treatment and fixation is still debated. The aim of this thesis was to study results after internal fixation of DRF AO type C.Study I (retrospective study, n=74) assessed outcomes after combined plating (CP) of DRFs AO type C, with 1-year follow-up. CP restored the anatomy and achieved a good functional outcome. The radiographic outcome did not correspond to the clinical or functional outcome.Study II (prospective study, n=97) assessed the prevalence of post-traumatic arthritis (PA) following CP of DRFs AO type C. CP yielded a good clinical outcome 7 years postoperatively and the prevalence of PA was low (29%). The presence of PA did not correlate with fracture group, radio-graphic, clinical, or functional outcome. Study III (randomized controlled trial, n=147) assessed the radiographic and clinical outcome following surgical treatment of DRFs AO type C, comparing volar plating (VP) with CP. Fixation with VP yieldedthe same radiographic and functional results as CP, but with a lower frequency of complications in the VP group.Study IV (prospective pilot study, n=10) assessed fragment migration with CTMA (CT-based micromotion analysis) after osteosynthesis with VP after DRF AO type C. The CTMA technique indicated that variable angle volar locking plate fixation can yield and maintain a stable reduction of the fracture fragments. CT volume registration could be a valuable tool in the detailed assessment of fracture fragment migration following VP fixation of DRFs.
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| 3. |
- Wildeman, Peter, 1975-
(författare)
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Prosthetic Joint Infection of the Hip : Cause and Effect
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Every year, 18 000 patients in Sweden and more than 1 million worldwide undergo total hip arthroplasty (THA). The operation is of great benefit to patients, but is associated with several complications. Prosthetic joint infections (PJIs) are among the most common complications, and can be devastating in terms of suffering for the patient and cost for the healthcare provider. The aim of this thesis was to investigate different aspects of PJIs in order to gain a better understanding of the causes and effects of infection. Four studies were conducted covering genomic analysis of the causative organism, identification of risk factors for failure of treatment, evaluation of a national infection control program aimed at reducing the burden of infections (PRISS: Prosthesis-related infections shall be stopped), and examination of the long-term impact of a PJI on the patient’s health through patient-reported measurement questionnaires.The main findings were as follows. Commensal bacteria such as Cutibacterium avidum have the potential to cause PJIs, and should be specially accounted for when performing hip surgery with an anterior approach. S. aureus is both a commensal and a pathogen with invasive capacity, and the commensal strains do not differ from the PJI strains regarding prevalence of virulence genes and clonal complexes. The genomic traits of pathogens had no impact on treatment success or eradication of infection in S. aureus PJIs The long-term effects of a PJI in the hip include increased mortality, lower quality of life, and decreased hip function. The incidence of PJIs was higher following the PRISS project. Increasing risk factors contributing to PJI explain the increasing incidence of PJI after primary THA.In conclusion, PJIs of the hip have multifactorial causes which are difficult to reduce, and long-term effects are severe.
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| 4. |
- Ahl, Rebecka, 1987-, et al.
(författare)
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A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery
- 2022
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Ingår i: European Journal of Trauma and Emergency Surgery. - : Urban und Vogel Medien und Medizin Verlagsgesellsc. - 1863-9933 .- 1863-9941. ; 48:2, s. 743-751
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: Despite advances in the care of hip fractures, this area of surgery is associated with high postoperative mortality. Downregulating circulating catecholamines, released as a response to traumatic injury and surgical trauma, is believed to reduce the risk of death in noncardiac surgical patients. This effect has not been studied in hip fractures. This study aims to assess whether survival benefits are gained by reducing the effects of the hyper-adrenergic state with beta-blocker therapy in patients undergoing emergency hip fracture surgery.METHODS: This is a retrospective nationwide observational cohort study. All adults [Formula: see text] 18 years were identified from the prospectively collected national quality register for hip fractures in Sweden during a 10-year period. Pathological fractures were excluded. The cohort was subdivided into beta-blocker users and non-users. Poisson regression with robust standard errors and adjustments for confounders was used to evaluate 30-day mortality.RESULTS: 134,915 patients were included of whom 38.9% had ongoing beta-blocker therapy at the time of surgery. Beta-blocker users were significantly older and less fit for surgery. Crude 30-day all-cause mortality was significantly increased in non-users (10.0% versus 3.7%, p < 0.001). Beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality (incidence rate ratio 0.28, 95% CI 0.26-0.29, p < 0.001) and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure.CONCLUSIONS: Beta-blockers are associated with significant survival benefits when undergoing emergency hip fracture surgery. Outlined results strongly encourage an interventional design to validate the observed relationship.
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| 5. |
- Forssten, Maximilian Peter, 1996-, et al.
(författare)
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A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients
- 2023
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Ingår i: European Journal of Trauma and Emergency Surgery. - : Urban und Vogel Medien und Medizin Verlagsgesellsc. - 1863-9933 .- 1863-9941. ; 49:3, s. 1485-1497
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.METHODS: This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.RESULTS: A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum.CONCLUSION: Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.
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| 6. |
- Forssten, Maximilian Peter, 1996-, et al.
(författare)
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Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index : a Swedish nationwide retrospective cohort study
- 2021
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Ingår i: Trauma surgery & acute care open. - : BMJ Publishing Group Ltd. - 2397-5776. ; 6:1
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.Methods: All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.Results: 134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.Conclusion: An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.Levels of evidence: Level III.
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| 7. |
- Forssten, Maximilian Peter, 1996-, et al.
(författare)
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The consequences of out-of-hours hip fracture surgery : insights from a retrospective nationwide study
- 2022
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Ingår i: European Journal of Trauma and Emergency Surgery. - : Springer. - 1863-9933 .- 1863-9941. ; 48:2, s. 709-719
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.METHODS: All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00-17:00) and out-of-hours surgery (17:00-08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.RESULTS: Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00-1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01-1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04-1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01-1.15), p = 0.022] compared to on-hour surgery.CONCLUSION: Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.
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| 8. |
- Forssten, Maximilian Peter, 1996-, et al.
(författare)
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The mortality burden of frailty in hip fracture patients : a nationwide retrospective study of cause-specific mortality
- 2023
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Ingår i: European Journal of Trauma and Emergency Surgery. - : Springer. - 1863-9933 .- 1863-9941. ; 49:3, s. 1467-1475
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.Methods: All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS & GE; 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.Results: After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].Conclusion: Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.
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| 9. |
- Joelson, Anders, 1970-
(författare)
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High-grade spondylolisthesis in young patients : Long-term results of in situ fusion
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The purpose of this long-term follow-up of 38 of 40 consecutive patients was to evaluate the results of uninstrumented in situ fusion for high-grade isthmic spondylolisthesis three decades after surgery. The mean age at surgery was 14 (range 9-24) years. The first of four studies evaluated clinical outcome, function, work status, and health-related quality of life (HRQoL) after in situ fusion in relation to age-matched Swedish population data. The second study evaluated effects on sagittal balance after in situ fusion. The third study evaluated adjacent segment disk degeneration after in situ fusion. The fourth study evaluated self-imageand HRQoL after in situ fusion in relation to healthy controls.The main findings were that (1) young patients fused in situ for highgrade isthmic spondylolisthesis have long-term HRQoL similar to the general Swedish population and controls matched for age and gender, (2) signs of non-compensated sagittal imbalance were observed only ina few individuals whereas compensated sagittal balance was the norm, (3) there was no correlation between any radiographic sagittal balance parameter and HRQoL outcome, (4) there was only a minor reduction inadjacent segment disk height which had no impact on HRQoL outcome, and (5) the only patient reported outcome measure indicating a detrimental effect at long-term follow-up was self-assessed trunk appearance which was slightly negatively affected.
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| 10. |
- Mohammad Ismail, Ahmad, 1993-, et al.
(författare)
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Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery : A Retrospective Cohort Study
- 2021
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Ingår i: Anesthesia and Analgesia. - : Lippincott Williams & Wilkins. - 0003-2999 .- 1526-7598. ; 133:5, s. 1225-1234
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery.METHODS: In this retrospective cohort study, all adults who underwent primary emergency hip fracture surgery in Sweden, between January 1, 2008 and December 31, 2017, were included. Patients with pathological fractures and conservatively managed hip fractures were excluded. Patients who filled a prescription within the year before and after surgery were defined as having ongoing BB therapy. The primary outcome of interest was postoperative mortality within the first year. To reduce the effects of confounding from covariates due to nonrandomization in the current study, the inverse probability of treatment weighting (IPTW) method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. These analyses were repeated while excluding patients who died within the first 30 days postoperatively. This reduces the effect of early deaths due to surgical and anesthesiologic complications as well as the higher degree of advanced directives present in the study population compared to the general population, which allowed for the evaluation of the long-term association between BB therapy and mortality in isolation. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI). Statistical significance was defined as a 2-sided P value <.05.RESULTS: A total of 134,915 cases were included in the study. After IPTW, BB therapy was associated with a 42% reduction the risk of mortality within the first postoperative year (adjusted HR = 0.58, 95% CI, 0.57-0.60; P < .001). After excluding patients who died within the first 30 days postoperatively, BB therapy was associated with a 27% reduction in the risk of mortality (adjusted HR = 0.73, 95% CI, 0.71-0.75; P < .001).CONCLUSIONS: A significant reduction in the risk of mortality in the first year following hip fracture surgery was observed in patients with ongoing BB therapy. Further investigations into this finding are warranted.
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