Henrik Palm

Copenhagen University Hospital Hvidovre · Hip Fracture Unit, Department of Orthopedics

This chapter explores the perioperative care of older people with significant fragility fractures requiring orthogeriatric care, with a focus on hip fracture as the most common of these injures. Surgery is the preferred treatment for most hip fractures. Perioperative care concerns the pre-, intra- and post-operative phase of the surgery. Principles...

Introduction Cut-out is the most frequently reported mechanical failure of internal fixation of pertrochanteric fractures. The purpose of this study was to examine if hydroxyapatite-coated screw thread on a sliding hip screw (SHS) could reduce screw migration within the femoral head in patients with stable pertrochanteric fractures. Materials and...

Introduction: The posterior approach (PA) for hemiarthroplasty (HA) in patients with femoral neck fracture (FFN) has a high risk of dislocation; however, by preserving the piriformis muscle, the dislocation rate could be lowered considerably. The aim of this study was to compare the surgical complications of the piriformis-preserving posterior app...

Background: The World Health Organization recommends a minimum of 150 min of moderate intensity exercise per week or 75 min of strenuous activity weekly for adults. Younger hip fracture patients are often assumed less active than the general population, however, knowledge on physical activity (PA) and health-related quality of life (HRQoL) in youn...

Background Several factors might be associated with risk of dislocating following uncemented hemiarthroplasty (HA) due to femoral neck fracture (FNF). Current evidence is limited with great variance in reported incidence of dislocation (1-15%). Aim of this study was to identify the true cumulative incidence of first-time dislocation following HA an...

Background: Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain. M...

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population. Introduction:...

Objective : to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complica...

Background: The purpose of the present multicenter cohort study was to compare the rates of reoperation in elderly patients with pertrochanteric and subtrochanteric fractures that had been treated with a short or long intramedullary nail. Methods: Eleven orthopaedic departments across Denmark delivered data that had been obtained from the Danish...

Objective To investigate the association of benzodiazepines and antidepressants on the risk of hospitalization and hip fracture in patients with dementia initiating antipsychotic drug treatment. Methods A register-based retrospective cohort study using data on all incident dementia cases (≥ 65 years) initiating antipsychotic treatment as monothera...

Introduction Undisplaced femoral neck fractures (FNFs) are usually treated by internal fixation (IF) but two randomised controlled trials (RCTs) have demonstrated advantages of treatment with arthroplasty. The complication rate was lowered but there were no clinically improved patient-reported outcome measures (PROM), which could be due to underpow...

Objective: To conduct a systematic review on the effect of posterior tilt on reoperations, patient reported outcome measures (PROM) and functional outcome following osteosynthesis of undisplaced FNFs (uFNF). Material and methods: A search string was developed with the aid of a scientific librarian and the search was performed in PubMed, CINAHL a...

Background and purpose — Most guidelines use patient age as a primary decision factor when choosing between osteosynthesis or arthroplasty in displaced femoral neck fractures. We evaluate reoperation and death risk within 1 year after osteosynthesis, and estimate the influence of age, sex, degree of displacement, and bone quality. Patients and meth...

Introduction: This study aims to investigate whether implant positioning is associated to risk of reoperation following internal fixation of undisplaced femoral neck fractures (FNF) with a posterior tilt < 20° in patients > 65 years. Method: Patients were retrieved from the Danish Multidisciplinary Hip Fracture Register in the period 2009-2013....

Background: Simulation-based training is emerging within the orthopaedic field to alleviate the challenges that trainees face such as work-hour restrictions, limited exposure to procedures, and increasing pressures to reduce risk to patients. This training modality has grown increasingly popular over the last 2 decades. However, integration into t...

PurposeThe inflammatory response to surgery can cause organ dysfunction that results in postoperative complications, including delirium. Methylprednisolone is an anti-inflammatory drug and could mitigate stress responses. This purpose of the study is to investigate the effects of a single high-dose methylprednisolone on various biomarkers in older...

Background: Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible...

Background and purpose — Orthopedic surgeons must be able to perform internal fixation of proximal femoral fractures early in their career, but inexperienced trainees prolong surgery and cause increased reoperation rates. Simulation-based virtual reality (VR) training has been proposed to overcome the initial steep part of the learning curve but it...

Background: early mobilization after hip fracture (HF) is an important predictor of outcome, but knowledge of the consequences of not achieving the pre-fracture basic mobility status in acute hospital recovery is sparse. Objective: we examined whether the regain of pre-fracture basic mobility status evaluated with the cumulated ambulation score...

This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO2), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO2 was determined using near-infrared spectroscopy...

Background: The purpose of this study was to estimate the incidence of reoperation and the effect of implant position on the risk of reoperation within 12 months following osteosynthesis with use of parallel implants for femoral neck fractures. Methods: From cases registered in the Danish Fracture Database, 1,206 consecutive surgeries for a prim...

Postoperative delirium is common after hip fracture surgery, and may have a neuro-inflammatory cause. We conducted a single-centre, randomised, double-blind, placebo-controlled trial of 117 older hip fracture patients to see if a single, pre-operative intravenous dose of 125 mg methylprednisolone could reduce the severity and/or incidence of postop...

Nonelderly hip fracture patients have gathered little scientific attention, and our understanding of the group may be biased by patient case-mix and lack of follow-up. Preconceptions may thwart adequate investigation of bone health and other comorbidities. This literature review focusses on who these patients between 20 and 60 years are, how to tre...

Background: The purpose of this study was to investigate whether surgical delay or the educational level of surgeon is associated with early mortality in patients with distal femoral fractures. Methods: 392 consecutive patients aged ≥50 years registered in the Danish Fracture Database for surgery of a non-pathological, closed, low-energy distal...

Hip fractures are operated with either prosthesis or various kinds of fracture fixation devices, with the aim of immediate mobilisation with full weight-bearing. Challenges are osteoporotic bone, bone vascularity, muscle-attachments, maintaining fracture reduction and slow fracture healing in the often-elderly population and, although reduced in re...

Question Is acute in-hospital physiotherapy with additional progressive knee-extension strength training (ST) of the fractured limb more effective in reducing knee-extension strength deficit at follow-up compared to physiotherapy without strength training in patients with a hip fracture? Design Assessor blinded, randomised controlled trial with in...

CONSORT 2010 checklist of information to include when reporting a randomised trial. (DOC)

Appendix 1. PT treatment exercise guide for patients with a hip fracture. (PDF)

Dataset of primary and secondary outcomes. (XLSX)

Study protocol. (DOC)

Purpose: The patient’s ability to complete their planned physiotherapy session after hip fracture surgery has been proposed as an independent predictor for achieving basic mobility independency upon hospital discharge. However, knowledge of factors limiting mobility is sparse. We therefore examined patient reported factors limiting ability to compl...

Hip fracture in frail, older adults (+ 65years) is commonly seen in Denmark. Early after hip fracture surgery, patients experience a substantial loss of muscle strength and independency in physical function. This place them at high risk of further functional decline, new falls and fractures, and subsequently compromised survival. Early physical reh...

Aims: We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip. Patients and methods: A single-centre placebo-controlled double-blinded randomised clinical...

Background/aims: Prior studies have shown that patients with dementia are at risk of receiving insufficient treatment for pain after a hip fracture. We therefore hypothesized that elderly hip fracture patients with dementia received less postoperative pain treatment than those without dementia. Method: All patients (age ≥65 years) who had been o...

Objectives: The aim of this study was to evaluate the intra-rater and inter-rater reliability of a scoring system for internal fixation (SIFA) in undisplaced femoral neck fractures (FNF). Design: A reproducibility study with a historical consecutive cohort. Setting: The patients were all treated at a Level One Trauma Hospital PATIENTS/PARTICIP...

Early mobilization following hip fracture surgery reduces medical complications and mortality, but may increase the risk of falling. The aim was to measure objectively the physical activity (time spent upright) the first week after hip fracture surgery, and relate it to functional performance and fear of falling at discharge. The 24-hour upright ti...

Introduction: Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark. Method: PubMe...

BACKGROUND: We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients. METHODS: We performed a retrospective analysis of prospectively collected data from the Danish Fracture Da...

Background and purpose — In traditional radiostereometric analysis (RSA), 1 segment defines both the acetabular shell and the polyethylene liner. However, inserting beads into the polyethylene liner permits employment of the shell and liner as 2 separate segments, enabling distinct analysis of the precision of 3 measurement methods in determining f...

Patients who are surgically treated for an acute hip fracture in Denmark commence early in-hospital physical rehabilitation (PR) with more than 95% of patients referred to further PR following discharge. However, the specifics of the PR services after discharge are unknown. Thus, the aim of the present paper was to describe the specifics of PR prov...

Background and purpose: Dislocation is one of the most common complications following hip arthroplasty. Delay until reduction leads to pain for the patient, and may increase the risk of complications. We investigated the safety aspect of a fast-track pathway for dislocated hip arthroplasties and evaluated its effect on surgical delay and length of...

Background and purpose Internal fixation of hip fractures is a common and important procedure that orthopedic surgeons must master early in their career. Virtual-reality training could improve initial skills, and a simulation-based test would make it possible to ensure basic competency of junior surgeons before they proceed to supervised practice o...

Patients with a hip fracture lose more than 50% knee-extension strength in the fractured limb within one week of surgery. Hence, immediate progressive strength training following hip fracture surgery may be rational, but the feasibility unknown. To examine the feasibility of in-hospital progressive strength training implemented in the acute ward fo...

Appendix 1 Twenty-six-page rehabilitation manual, which includes pictorial supplemented mobilisation and training exercises for all patients after hip arthroscopy.

Background Patient-specific clinical pharmacy services practiced in Danish hospitals have developed rapidly over the past decade. With respect to tailoring the services to need and cost this study has focused on the further use of pharmaconomists in selected steps in the medication management process freeing up pharmacist time for other input in th...

The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI). From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17-63) and 32 males (median age 38, range 15-59)] underwent hip arthroscopy and la...

Reoperations are common after surgical treatment of hip fractures but may be reduced by optimal choice of implant based on fracture classification. We hypothesized that implementing a surgical treatment algorithm was possible in our hospital and would result in a reduced reoperation rate. Retrospective comparative study. Provincial level III trauma...

Purpose: Hip fracture treatment is controversial, with high complication rates. An algorithm for hip fracture surgery has shown reduced reoperation rates, but choice of implant is based on the commonly used fracture classifications, which were previously evaluated to be unreliable. The purpose of this study was to investigate the reliability of th...

BACKGROUND: Highly crosslinked polyethylene (HXLPE) in THA was developed to reduce particle-induced periprosthetic osteolysis. A series of clinical studies were initiated to determine the clinical efficacy as judged by patient-reported scores, radiographic osteolysis, and wear analysis of one form of HXLPE. QUESTIONS/PURPOSES: The purposes of this...

Immediate weight-bearing following osteosynthesis of proximal tibial fractures is traditionally not allowed due to fear of articular fracture collapse. Anatomically shaped locking plates with sub-articular screws could improve stability and allow greater loading forces. The purpose of this study was to investigate if immediate weight-bearing can be...

Abstract: Background: Hip arthroscopy for femoro-acetabular impingement (FAI) has shown substantial clinical improvements after 1 to 2 year. The short-term clinical outcome within the first year have however not been evaluated substantially, including studies of when the observed clinical improvement occurs. Purpose: The purpose of this study was...

Fixation of unstable trochanteric fractures is challenging. Application of a circumferential wire may facilitate bone contact and avoid postoperative fracture displacement. However, the use of circumferential wires remains controversial due to possible disturbance of the blood supply to the underlying bone. We evaluated the results of applied circu...

Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results. 2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were pros...

In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fracture...

Although the clinical consequences of femoroacetabular impingement have been well described, little is known about the prevalence of the anatomical malformations associated with this condition in the general population, the natural history of the condition, and the risk estimates for the development of osteoarthritis. The study material was derived...

A stress fracture of the calcaneus is the result of rhythmically recurring sub-threshold traumata and is typically seen in athletes. The diagnosis is difficult because stress fractures are easily missed in traditional radiographs. It is therefore recommended to perform magnetic resonance imaging. Treatment includes paracetamol and rest - and in sev...

In Denmark, 10,000 patients with hip fractures are annually admitted to hospital. These patients are generally old with a high degree of comorbidities. Current treatment strategies for peri- and postoperative treatment are presented in relation to patient reconvalescence. Overall expected hospitalization is 5-25 days with 1-3 months of analgesic tr...

Preoperative posterior tilt in undisplaced (Garden I-II) femoral neck fractures is thought to influence rates of reoperation. However, an exact method for its measurement has not yet been presented. We designed a new measurement for posterior tilt on preoperative lateral radiographs and investigated its association with later reoperation. A consecu...

Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown. A total of 120 elderly, cognitively intact hip fracture patients admitted from their own home were randomly assigned to receive transfus...

Hip fracture patients experience high pain levels during postoperative rehabilitation. The role of surgical technique on postoperative pain has not been evaluated previously. One hundred and seventeen hip fracture patients were included in a descriptive prospective study. All patients received continuous epidural analgesia and were treated accordin...

The functional and radiological outcome of cemented Neer II hemiarthroplasty performed within six weeks after a fracture-dislocation or a three/four-part humeral head fracture was evaluated in 48 patients with an average age of 73 years (range: 45 to 89), with an average follow-up period of 44 months (range: 6 to 106). Thirty-two (67%) patients wer...

Femoroacetabular cam impingement is thought to be a cause of premature osteoarthritis of the hip. The presence of cam malformation was determined in 2803 standardised anteroposterior (AP) pelvic radiographs from the Copenhagen Osteoarthritis Study by measuring the alpha (α) angle and the triangular index, a new measure of asphericity of the femoral...