Pelvic and acetabular injuries are uniquely demanding due to complex three-dimensional anatomy, the proximity of critical neurovascular structures, and the incidence of these fractures in elderly, a well as and polytrauma patients, is increasing. While existing courses focus heavily on acute surgical management and established techniques, they often omit critical subjects such as complication management, revision strategies, and interdisciplinary care. To establish an international benchmark for surgical excellence in pelvic surgery, the proposed program may utilize a competency-based framework divided into three parts: Part 1: Theoretical Foundation: Independent study of biomechanics, pathology, and operative planning, validated by a rigorous multiple-choice examination. Part 2: Surgical Skills Assessment: Evaluation of technical precision and intraoperative decision-making within a controlled wet lab environment. Part 3: Clinical Reasoning & Reflection: Expert-led discussions centered on the participant’s own clinical cases, focusing on evidence-based reasoning and the management of complex revisions. By standardizing these advanced competencies, the program aims to ensure surgeons possess both the technical proficiency and the mature clinical judgment required to deliver high-quality care for complex pelvic and acetabular trauma cases.

BACKGROUND:Trauma is a major global health burden leading to significant morbidity, disability, and mortality. Predictive models in trauma care traditionally focus on mortality, but early predictions of hospital length of stay (LOS) and intensive care unit (ICU) needs could greatly enhance hospital planning and resource allocation. Machine learning (ML) offers new possibilities for developing prediction tools for these outcomes but remain underexplored in large, unselected trauma populations. AIM:To develop and validate machine learning-based models for early prediction of hospital length of stay and ICU admission among severely injured trauma patients using a large patient cohort from a national trauma registry. METHODS:Patient data from 9056 adult severely injured trauma patients (NISS >15) registered in the Swedish trauma registry SweTrau between 2015 and 2019 were analyzed. Only variables available at hospital arrival were used as predictors. Outcomes were LOS (1-2, 3-9, or ≥10 days) and ICU admission (yes/no). Patients from 2015 to 2018 (n = 6706) were used for training Generalized Linear Model (GLM), Random Forest (RF), and Extreme Gradient Boosting (XGB) models, and patients from 2019 (n = 2350) were used for temporal internal-external validation. Model performance was assessed with ROC curves, calibration curves and DCA. RESULTS:The XGB models consistently outperformed GLM and RF models for all outcomes. For estimation of ICU admission, the XGB model achieved an AUC of 0.85 (95% CI: 0.84-0.87). For estimations of LOS, the XGB model achieved "one-vs- all" AUCs of 0.69, 0.64, and 0.71 for the three LOS categories, respectively. A clinical prediction tool based on the best-performing models was created and is available online (https://hipfx.shinyapps.io/traumaadvisorapp/). CONCLUSION:Machine learning models trained on national trauma registry data demonstrated strong performance in predicting ICU admission and moderate accuracy in categorizing hospital length of stay. The XGB model showed the highest overall predictive power and may serve as a useful tool to support early triage, guide clinical decision-making, and optimize resource allocation in trauma care settings.

Background and purpose: Elderly patients with acetabular fractures are associated with complex fracture patterns and poor bone quality. Internal fixation alone in these patients has been associated with poor outcome. Internal fixation combined with acute total hip arthroplasty (THA) has been introduced as a surgical option aimed to allow early recovery of hip function and mobility. However, functional and radiological data are still limited. The aim of our study was to elucidate radiographic and functional outcomes, and complications in elderly patients with an acetabular fracture treated with acute THA and additional fixation (reinforcement ring and/or plate fixation). Methods: Patients ≥ 60 years with an acetabular fracture treated with acute THA and additional acetabular fixation were followed up at least 1 year postoperatively. Medical records were reviewed, and functional examinations and radiographic assessments were performed. Results: 84 patients were identified, of whom 32 completed all follow-ups. The median (IQR, range) age was 77 (35, 60–95) years and 7 of 32 were females. Dome impaction was the main indication for THA in 30 and the median follow-up time was 3.1 years. 2 patients had a postoperative hip dislocation. 3 patients had a deep infection and 7 sustained at least 1 non-surgical complication. The median Harris Hip Score was 87 (33, 33–100) and the median EQ-5D-3L index score was 0.7 (0.5, 0.0–1.0). No radiological signs of loosening of the acetabular reinforcement ring or the cup were observed. The 1-year mortality for the whole eligible cohort was 13% (n = 9/72). Conclusion: Internal fixation with acute THA in elderly acetabular-fracture patients resulted in good functional outcomes with no signs of acetabular implant loosening, but a high complication rate.

A periacetabular osteotomy (PAO) is a joint-preserving surgical option for treatment of acetabular dysplasia. The procedure aims to prevent, or at least delay, the development of osteoarthritis, and subsequent need for total hip arthroplasty (THA). The conversion rate to THA differs widely in the literature, but most of the studies have few patients, and the follow-up time is often short for THA as an endpoint. The aim of this study was to evaluate the long-term outcome after PAO surgery with the rate of conversion to THA as the primary outcome. Patients ≥18 years that underwent a PAO operation at the Karolinska University Hospital in Stockholm, Sweden from 2006 to 2022 were included. Radiological signs of hip osteoarthritis, and the lateral center-edge angle (LCEA) was calculated on pre- and postoperative radiographs or CT-scans. The national Swedish Arthroplasty Register was used to find cases who had a secondary operation with THA. The number of cases included was 96. Median age was 30 (18–46) years, and 84

The number of acetabular fractures in the elderly population is increasing. Non-surgical treatment in these patients have been associated with poor outcomes. A primary total hip arthroplasty (THA) in combination with additional acetabular fixation (“fix and replace”) has been suggested to prevent complications associated with inactivity and to allow an active independent life. Although the reported results are promising, most of the so far published series are relatively small and with short follow-up times. All patients aged from 60 years that underwent an acute primary THA with additional fixation (plate and/or cage) due to an acetabular fracture at the Karolinska University Hospital in Stockholm, Sweden from 2017 to 2023 were identified. Medical records including radiographs were manually reviewed and follow-up was a minimum of 1 year. A total of 70 patients were included. The median age was 78 (60–95) years, and 26

Our purpose was to assess the prevalence of liver injuries as well as concomitant injuries to the liver and spleen in patients with blunt or penetrating abdominal trauma, and to determine the prevalence, management and outcome of active bleeding and contained vascular injuries (CVI; pseudoaneurysm/AV-fistula) seen on admission CT. A retrospective, single-center, longitudinal cohort study with nine-year data (2013–2021) of all ≥ 15-year-old patients with severe blunt or penetrating abdominal trauma and an ICD code for liver and/or splenic trauma. CT examinations were identified. Radiology, medical reports and images were reviewed and only patients with an adequate admission CT were included in the final study group. Of 2805 patients with abdominal trauma (71% males), 409 patients (14.6%) had a liver injury, and 329 had a CT on admission (329/409; 80.4%). 313 patients (11.2%) had a splenic injury and 262 had a CT (262/313; 83.7%). Of these, 65 patients or 2.3% (65/2805) had injury to both organs, with 49 patients with CT (49/65; 75.4%), combined group (CG) (79% males). The median (range) ISS was 21 (4–75) for single organ injury patients and 34 (9–75) for patients with both organs injured (p < 0.0001). Active liver or splenic bleeding was seen in 5.8% and 17.9%, respectively. In CG, 11 (11/49; 22.4%) patients had active bleeding. Of these, two patients had active bleeing in both organs (4.1%). Liver patients with active bleeding had significantly higher ISS (p = 0.025) than those without. In CG, ISS did not differ significantly between patients with and without active bleeding (p = 0.073), however, it tended to be higher in those with active bleeding. Most liver injuries with active bleeding were treated non-operatively (12/19; 63.2%). An active bleeding was more common in spleen than in liver patients; odds ratio (OR) (95% CI) 3.57 (2.04–6.25), p < 0.0001. A CVI was more common in splenic compared with liver injuries, OR 6.71 (95% CI; 2.27–19.9, p < 0.0001). Active bleeding was more common in CG than in single organ injury patients; OR 3.67 (1.73–7.79), p < 0.0016. 30-day survival rate did not differ between patients with or without active bleeding, but was slightly lower in CG compared with only liver injury (89.8% vs. 93.7%, p = 0.36). In conclusion the prevalence of liver injury in abdominal trauma seen on admission CT was 11.7% of all patients with blunt or penetrating abdominal trauma, and concomitant splenic and liver injury was seen in 1.7%. Non-operative management was applied in almost two thirds of patients with liver injuries. Active bleeding was seen in 5.8% of liver, 17.9% of splenic and 22.4% of CG patients. ISS was doubled in CG compared with single organ injury patients. Active bleeding was more common in CG, and CG had slightly increased mortality rate compared with single organ injury patients.

BACKGROUND:Given the huge impact of trauma on hospital systems around the world, several attempts have been made to develop predictive models for the outcomes of trauma victims. The most used, and in many studies most accurate predictive model, is the "Trauma Score and Injury Severity Score" (TRISS). Although it has proven to be fairly accurate and is widely used, it has faced criticism for its inability to classify more complex cases. In this study, we aimed to develop machine learning models that better than TRISS could predict mortality among severely injured trauma patients, something that has not been studied using data from a nationwide register before. METHODS:Patient data was collected from the national trauma register in Sweden, SweTrau. The studied period was from the 1st of January 2015 to 31st of December 2019. After feature selection and multiple imputation of missing data three machine learning (ML) methods (Random Forest, eXtreme Gradient Boosting, and a Generalized Linear Model) were used to create predictive models. The ML models and TRISS were then tested on predictive ability for 30-day mortality. RESULTS:The ML models were well-calibrated and outperformed TRISS in all the tested measurements. Among the ML models, the eXtreme Gradient Boosting model performed best with an AUC of 0.91 (0.88-0.93). CONCLUSION:This study showed that all the developed ML-based prediction models were superior to TRISS for the prediction of trauma mortality.

Contained vascular injuries (CVI) of spleen include pseudoaneurysms (PSA) and arterio-venous fistulae (AV-fistulae), and their reported prevalence varies. Our purpose was to assess the prevalence of early splenic CVI seen on admission CT in patients with splenic trauma admitted to a single level 1 trauma center in 2013–2021, and its detection in different CT protocols. A retrospective, single-center longitudinal cohort study. Nine-year data (2013–2021) of all patients with suspected or manifest abdominal trauma were retrieved. All patients, > 15 years with an ICD code for splenic trauma (S36.0XX) were included. CT and angiographic examinations were identified. Reports and images were reviewed. Splenic CVI CT criterion was a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Number of CVIs and treatment was based on medical records and/or available angioembolization data. Of 2805 patients with abdominal trauma, 313 patients (313/2805; 11.2%) fulfilled the study entry criteria. 256 patients (256/313; 81.8%) had a CT examination. Sixteen patients had splenectomy before CT, and the final study group included 240 patients (240/313; 76.7%). Median New Injury Severity Score (NISS) was 27 and 87.5% of patients had NISS > 15. Splenic CVI was found in 20 patients, which yields a prevalence of 8.3% (20/240; 95% CI 5.2–12.6%). In those cases with both late arterial and venous phase images available, CVI was seen in 14.5% of cases (18/124, 95% CI 8.6–22.0%). None of the patients with CVI died within 30 days of the injury. The prevalence of early splenic CVI in patients with a splenic trauma was 8.3–14.5% (95% CI 5.2–22.0%). Our data suggests that both arterial and venous phase are needed for CT diagnosis. The 30-day outcome in terms of mortality was good.

Background SARS-CoV-2 has had an extensive influence on orthopaedic surgery practice and has been associated with an increased risk of mortality. There is limited evidence of how this pertains to acute orthopaedic surgery with inpatient care. Methods A retrospective cohort study on traumatic fracture patients requiring inpatient care between February 25, 2020 and March 25, 2021 was conducted. Patients were grouped by perioperative SARS-CoV-2 infection, defined as a positive SARS-CoV-2 test from 7 days before to 7 days after orthopaedic surgery, and compared using linear regression and Cox proportional hazards model for primary outcome 30-day mortality and secondary outcome hospital length of stay. Results In total, 5174 adults with a length of stay ≥ 48 h and an orthopaedic procedure due to a registered traumatic fracture were admitted from February 25, 2020 and discharged before March 26, 2021. Among the 5174 patients, 65% (3340/5174) were female, 22% (1146/5174) were 60–74 years and 56% (2897/5174) were 75 years or older. In total, 144 (3%) had a perioperative SARS-CoV-2 infection. Perioperative SARS-CoV-2 infection was associated with an increased 30-day mortality (aOR 4.19 [95% CI 2.67–6.43], p < 0.001). The median (IQR) length of stay after surgery was 13 days (IQR 6–21) for patients with, and 7 days (IQR 2–13) for patients without, perioperative SARS-CoV-2 infection. Conclusions Perioperative SARS-CoV-2 infection increased 30-day mortality risk and hospital length of stay for traumatic fracture patients requiring inpatient surgical care. Pre- and postoperative infection were both associated with similar increases in mortality risk.

Acetabular fractures are injuries often surgically treated, but the surgical intervention is associated with a high risk of subsequent complications. The primary aim of this study was to explore the rate of reoperations and to identify potential risk factors for reoperation. Secondary aims were other adverse events and mortality. Patients ≥ 18 years with a surgically treated acetabular fracture at a single trauma center in Sweden between 2010 and 2019 were retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to investigate factors associated with reoperations and other adverse events. A total of 229 patients with a surgically treated acetabular fracture were included, mean age (± SD, range) 60 (19, 19–94) years. The majority of the patients were males (n = 180, 79

Purpose High-energy pelvic fractures are complex injuries often requiring surgical treatment. Different radiological methods exist to evaluate the reduction and healing process postoperatively but with certain limitations. The aim of this study was to evaluate Computed Tomography Micromotion Analysis (CTMA) in a clinical setting for follow-up of surgically treated pelvic fracture patients. Methods 10 patients surgically treated for a pelvic fracture were included and prospectively followed with Computed Tomography (CT) at 0, 6, 12 and 52 weeks postoperatively. CTMA was used to measure postoperative translation and rotation of the pelvic fracture during the 52 weeks follow-up. Clinical outcomes were collected through the questionnaires EQ-5D index score and Majeed score. Results 10 patients were included with mean age (± SD, min–max) 52 (16, 31–80) years and 70% ( n = 7) were males. The median (IQR, min–max) global translation from 0 to 52 weeks was 6.0 (4.6, 1.4–12.6) millimeters and median global rotation was 2.6 (2.4, 0.7–4.7) degrees. The general trend was a larger translation between 0 and 6 weeks postoperatively compared to 6–12 and 12–52 weeks. For the clinical outcomes, the general trend was that all patients started from high scores which decreased in the first postoperative follow-up and recovered to different extent during the study period. Conclusion CTMA was successfully used in the follow-up of surgically treated pelvic fracture patients. Movement in the pelvic fractures after surgical fixation was largest between 0 and 6 weeks.

Background Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality. Methods All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. Results A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18–94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2). Conclusions Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality.

Background and purpose: Trauma causes over 4 million annual deaths globally and accounts for over 10% of the global burden of disease. Trauma patients often sustain multiple injuries in multiple organ systems. We aimed to investigate the proportion and distribution of musculoskeletal injuries in adult trauma patients. Patients and methods: This is a register-based study using data from the national Swedish trauma register (SweTrau) collected in 2015–2019. By categorizing Abbreviated Injury Scale (AIS) codes into different injury types, we provide a detailed description of the types of musculoskeletal injuries that occurred in trauma patients. Results: 51,335 cases were identified in the register. After exclusion of 7,696 cases that did not have any trauma diagnosis (AIS codes) registered from the trauma and 6,373 patients aged < 18, a total of 37,266 patients were included in the study. 15,246 (41%) had sustained musculoskeletal injury. Of the patients with musculoskeletal injuries, 7,733 (51%) had more than 1 such injury. Spine injuries were the most common injury location (n = 7,083 patients, 19%) followed by lower extremity injuries (n = 5,943 patients, 16%) and upper extremity injuries (n = 6,273 patients, 17%). Fractures were the dominating injury type with 30,755 (87%) of injuries being a fracture. Conclusion: 41% of the trauma patients had at least 1 musculoskeletal injury. A spine injury was the most common injury location. Fractures was the dominating injury type constituting 87% of all injuries. We also found that half the patients (51%) with spine or extremity injuries had ≥ 2 such injuries.

Background Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality. Methods Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality. Results A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18–98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3–3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3–6.0), ASA class 3–4 (OR 2.3, 95% CI 1.4–3.6), GCS 1–8 (OR 21, 95% CI 13–33) and NISS > 15 (OR 4.2, 2.4–7.3). Conclusion Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

To describe the epidemiology of Pipkin fractures including detailed fracture classification and outcome for joint preservation and death. We extracted data on all Pipkin fractures in the Swedish Fracture Register from 2013 to 2020 in patients ≥ 18 years. The cohort was cross-matched with the Swedish Hip Arthroplasty Register to obtain data on primary or secondary treatment with arthroplasty. We analysed data on age, sex, injury mechanism, fracture classification, treatment including secondary operative treatment with arthroplasty and mortality. Primary outcome was joint preservation. In total 47 Pipkin fractures with a median age of 48 years were included. 74% of the fractures were in males. The median follow-up time was 3.5 years. The most common primary treatment was internal fixation (45%), followed by primary arthroplasty (28%), and excision of fragment (15%). Three of the 34 patients with primary non arthroplasty treatment received secondary treatment with arthroplasty. Two patients died within 30 days, and no further deaths occurred up to 1 year after injury. Three of four fractures occurred in males and more than half of the fractures were due to high energetic injuries. Half of the patients received internal fixation (predominantly younger patients) and 28% were treated with primary arthroplasty (predominantly older patients). The revision rate was low, and after secondary treatment with arthroplasty two thirds of the patients still had a preserved joint.

Objectives: To validate the classification of surgically treated acetabular fractures in the Swedish Fracture Register (SFR) and to investigate the intra-and interrater reliability of the Judet-Letournel / AO/OTA classification systems.Methods: Surgically treated acetabular fractures were randomly selected from the SFR ( n = 132) and 124 fractures were classified independently by three experienced orthopedic pelvic surgeons at two different occasions. A gold standard classification was established for each case after these two sessions or, if necessary, after a discussion session. The gold standard classification was compared to the registered SFR classification to assess the validity of SFR data. Accuracy and intra-and interrater agreement were evaluated using Cohen s acute accent kappa with interpretation according to Landis and Koch.Results: There was moderate agreement between the established gold standard classification and the SFR (kappa 0.43). The level of agreement differed between classification groups. The intrarater agreement was substantial to almost perfect and interrater agreement was moderate to substantial.Conclusions: The accuracy of acetabular fracture classifications in the SFR was moderate and comparable to previous validation studies from the SFR on other fracture types. As the accuracy differed between fracture groups, care should be taken when analyzing data from the SFR on specific acetabular fracture groups. (c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

Surgical treatment of pelvic fractures is an advanced intervention associated with multiple complications. The primary aim of this study was to investigate the rate of unplanned reoperations after pelvic fracture surgery. Secondary aims included occurrence of other adverse events and mortality. All adult patients ≥ 18 years with surgically treated pelvic fracture operated at the Karolinska University Hospital in Sweden between 2010 and 2019 were identified and retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. A total of 194 patients were included with mean age (± SD, range) 45.4 (16, 18–83) years. 62

Abstract Purpose Trauma causes over 4 million annual deaths globally and accounts for over 10 % of the global burden of disease. Trauma patients often sustain multiple injuries in multiple organ systems. This study aims to investigate the incidence of orthopaedic injuries in adult trauma patients.MethodsThe study was a register-based study using data from the national Swedish trauma register – SweTrau. The inclusion criteria for the register are all patients with a trauma that activated the trauma team at the admitting hospital, or patients admitted without trauma team activation but with NISS (New Injury Severity Score) >15. By categorizing Abbreviated Injury Scale (AIS) codes into different orthopaedic injury types, we provided a detailed description of what types of orthopaedic injuries that occurred in trauma patients.ResultsA total of 37266 patients were included in the study. A total of 15246 (40%) patients had sustained any orthopaedic injury, and 7733 (51%) patients had more than one orthopaedic injury. Spine injuries were the most common type of injury affecting 19% (n= 7083) of all trauma patients, followed by injuries of the upper extremities (n=6273, 17%) and lower extremities (n=5943, 16%). Fractures were the domination type of orthopaedic injury (n=30755, 87%). Traffic injury was the most common injury mechanism with almost half (n= 18112, 49%) of the patients being admitted after some sort of traffic related incidentConclusionOrthopaedic injuries are common in trauma and occur in 40% of trauma patients. Slightly more than half of the patients with orthopaedic injury had ≥2 orthopaedic injuries.

Background and purpose — Fractures of the pelvis and femur are serious and potentially lethal injuries affecting primarily older, but also younger individuals. Long-term trends on incidence rates and mortality might diverge for these fractures, and few studies compare trends within a complete adult population. We investigated and compared incidence and mortality rates of pelvic, hip, femur shaft, and distal femur fractures in the Swedish adult population. Patients and methods — We analyzed data on all adult patients ≥ 18 years in Sweden with a pelvic, hip, femur shaft, or distal femur fracture, through the Swedish National Patient Register. The studied variables were fracture type, age, sex, and 1-year mortality. Results — While incidence rates for hip fracture decreased by 18% (from 280 to 229 per 105 person-years) from 2001 to 2016, incidence rates for pelvic fracture increased by 25% (from 64 to 80 per 105 person-years). Incidence rates for femur shaft and distal femur fracture remained stable at rates of 15 and 13 per 105 person-years respectively. 1-year mortality after hip fracture was 25%, i.e., higher than for pelvic, femur shaft, and distal femur fracture where mortality rates were 20–21%. Females had an almost 30% lower risk of death within 1 year after hip fracture compared with males. Interpretation — Trends on fracture incidence for pelvic and femur fractures diverged considerably in Sweden between 2001 and 2016. While incidence rates for femur fractures (hip, femur shaft, and distal femur) decreased or remained constant during the studied years, pelvic fracture incidence increased. Mortality rates were different between the fractures, with the highest mortality among patients with hip fracture.

Rotational deformities following intramedullary (IM) nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or Computed Tomography (CT) comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs. Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. CT-based motion analysis (CTMA) was used and the mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated. Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (95% CI − 2.959–.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (95% CI .370–1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes. Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.