Category Archives: Research

Collum screw – to parallel or not

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Two bridges

Bridging the knowledge gap in how to operate femoral neck fractures. The image is CC by Nick Mealey.

One of the first surgeries young orthopaedic surgeons learn is the femoral neck fracture fixation with collum screws. A common theme is how to position the screws and as a young surgeon one often believe that everything depends on the screw position, especially if they’re parallel or not. It was therefore quite fun and liberating to read Nyholm et al’s study with the subtitle: “Minimal Effect of Implant Position on Risk of Reoperation” Continue reading →

And I thought we were done with the mid-shaft clavicle….

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Bicycle

Bicycle injuries are by far the most common mechanism of injury for clavicle injuries. The image is CC by Hiroyuki Takeda.

So… just a few days after my previous clavicle post, Ahrens et al released their multi-center study on 300 patients randomized to surgery. They found that operated clavicles have less pain early on, but that after 9 months they perform the same. The study was excellently performed with 20 centers, adequate patient selection, random block permutation for treatment allocation, and reasonable treatment options. Continue reading →

The clavicle fracture – can the madness finally come to an end?

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Finding the right path can be harder than we want to think . The image is CC by Gwenole Camus.

In the early 2000s Nowak et al. [1] shattered the belief that mid-shaft clavicle fractures always healed fine; even after 10 years almost half of the patients had remaining symptoms*. This common injury had also by in others [2] (with shorter follow-ups) been hinted as problematic, and within short we were showered with fancy new implants. After ≥ 7 RCTs [3], [4] on the subjects it seems that these new implants failed do deliver. Can we finally start questioning if surgery is the solution? Continue reading →

ASA as DVT prophylaxis gaining in popularity?

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Keeping the blood flowing is part of core medical knowledge – then why the controversy? The image is CC by Andi Campbell-Jones

In a recent post I noted that there was a dissonance between what I’ve been taught in school and what is actually the case regarding thrombosis prophylaxis after orthopaedic surgery. A new study by Parvizi et. al. looks into different dosages of ASA as a thromboprophylaxis after joint arthroplasties. Coming from a country that has fully embraced LMWH this feels alien… regardless, there seems to be increasing evidence that challenges my point of view. Continue reading →

Chochrane supports restrictive transfusions

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Will Cochrane break through to the blood thirsty colleagues? The image is CC by Gaviota Paseandera.

Will Cochrane break through to the blood thirsty colleagues? The image is CC by Gaviota Paseandera.

I’ve previously written a two posts on blood transfusions from a surgeons perspective (End of the blood reign and A bloody mess) and I was therefore thrilled when I stumbled upon this [Cochrane review](https://www.ncbi.nlm.nih.gov/pubmed/27731885) that concludes:

The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.

Continue reading →

Dealing with non-proportional hazards in R

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As things change over time so should our statistical models. The image is CC by Prad Prathivi(

As things change over time so should our statistical models. The image is CC by Prad Prathivi

Since I’m frequently working with large datasets and survival data I often find that the proportional hazards assumption for the Cox regressions doesn’t hold. In my most recent study on cardiovascular deaths after total hip arthroplasty the coefficient was close to zero when looking at the period between 5 and 21 years after surgery. Grambsch and Thernau’s test for non-proportionality hinted though of a problem and as I explored it there was a clear correlation between mortality and hip arthroplasty surgery. The effect increased over time, just as we had originally thought, see below figure. In this post I’ll try to show how I handle with non-proportional hazards in R. Continue reading →

LMWH – a Big Pharma bluff?

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Tales of Big Pharma Horror. The image is CC from Mike Licht.

Tales of Big Pharma Horror. The image is CC from Mike Licht.

Thromboprophylaxis is a given for patients operated due to lower limb injuries, at least if we believe Big Pharma-studies. This dogma is now challenged by a double-blind, multi-center, RCT by Selby et al. They found that the DVT rate was much lower than expected and had to pull the plug on the study as it would be practically impossible to show a difference between placebo and LMWH. Continue reading →

Canakinumab – difficult to pronounce but useful for treating gout?

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Gout onset is sudden and be intensely painful. The image is CC by Mike

Gout onset is sudden and be intensely painful. The image is CC by Mike

Gout can be incredibly painful where the main treatment option are nonsteroidal anti-inflammatory drugs (NSAID). Unfortunately NSAIDs are not the best alternative for elderly patients as it may induce heart & kidney failure. I was therefore thrilled to see that canakinumab recently was approved by Läkemedelsverket as a treatment alternative. Continue reading →

The proximal humerus fracture – a lost cause?

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Time to give up on the proximal humerus fracture? The image is CC by Crouchy99.

Time to give up on the proximal humerus fracture? The image is CC by Crouchy99.

Most orthopaedic surgeons have met patients with poor shoulder function after a proximal humerus fracture, and many of us have thought: if I’ve only done the other thing I was thinking of…. Unfortunately the outcome seems to be independent of what we do, at least according to Launonen et al’s meta-analysis and Rangan et al’s recent RCT on 250 patients. Continue reading →

A bloody mess

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Is the evidence on blood transfusions going down the drain? The image is CC by Steve Koukoulas.

Is the evidence on blood transfusions going down the drain? The image is CC by
Steve Koukoulas.

In a recent RCT by Gregersen et al. they manage to complicate  blood transfusions in orthopaedic patients even further. They suggest that orthopaedic patients from nursing homes fare better with liberal blood transfusions (> 113 g/L compared to >97 g/L). The concept is interesting, although the paper has some issues. Continue reading →