Mortality after proximal femur fracture with a delay of surgery of more than 48 h

Purpose

For hip fractures, guidelines require surgery as soon as possible, but not later than 48 h. Some authors observed a positive and some a negative effect of early operation on mortality rate. The aim was to evaluate the mortality rate of patients with a delay of surgery >48 h after admission, as well as influencing factors and reasons for delay.

Methods

One hundred and thirty-six patients with hip fractures (>65a) from 2007 to 2011 were included. Comorbidities, the American Society of Anaesthesiologists (ASA) classification, time of admission and surgery, and mortality were recorded up to 12 months. Reasons for delay were divided into administrative-related or patient-related. The following time intervals were observed: 48.01–72 h (2–3 days), 72.01–120 h (3–5 days), 120.01–168 h (5–7 days), 168 h (>7 days).

Results

94.9 % of the reasons for delay were patient-related. The mean survival times of the first three intervals were almost the same (9.5–9.9 months) (p = 0.75). The last group had a significantly shorter survival time (7.8 months). Summarizing the first three groups, a significant shorter (p = 0.03) survival time and significantly higher (p = 0.04) 12-month mortality rate in patients with a delay >7 days was observed. The probability of death was primarily dependent on the ASA classification (p < 0.0001) and secondarily on the patient’s age at the time of injury (p = 0.005).

Conclusions

In hip fractures, reasons for a delay >48 h are mainly patient-related. A delay up to 7 days did not influence survival time and mortality negatively. The higher the value of the ASA classification and the older the patient was at the time of injury, the higher the mortality rate and the shorter the survival time.     

Periprosthetic fractures of the proximal femur—Vancouver A type fracture

Introduction

Today, we encounter an increasingly high need for arthroplasty, with a high number of total hip arthroplasties. With this, complications also rise, such as periprosthetic fractures. The purpose of this article is to briefly expose the periprosthetic fracture type Vancouver A, which is located either around the greater or the lesser trochanter.

Lesser trochanter fractures

The fractures of the lesser trochanter occur either through a low-energy trauma or spontaneously in the context of an osteolysis after loosening of the stem. The healing can mostly be achieved conservatively. In rare cases, an operative treatment must be considered, as in cases of osteolysis or lack of medial support, where a stem revision can become necessary.

Greater trochanter fractures

Also, the greater trochanter fractures are an entity of low-energy trauma. In cases of little displacement or in patients with low demand, a conservative treatment is indicated. For all other cases, there are a number of different methods of fixation. They range from wire cerclages to angular stable plates or even gluteus maximus/fascia lata flap transfer. However, a relatively high incidence of non-unions has been reported with different fixation techniques. The high incidence of non-union of periprosthetic fractures of the greater trochanter could eventually solved with the use of angular stable implants. There seem to be certain advantages, but further and larger studies will be necessary to prove its value.     

Intracapsular fracture of the proximal femur——Operative versus nonoperative management

Taken together, these reports do not provide strong evidence in favor of either internal fixation or arthroplasty over the other relative to mortality in the treatment of intraeapsular fracture of the proximal femur. However, they do suggest a higher rate of reoperations in those receiving internal fixation compared with arthroplasty. Differing patient characteristics at baseline make direct comparisons difficult.     

Does technique alter quality of life after pilonidal sinus surgery?

BACKGROUND: Pilonidal sinus is a common disease in young adults that carries high postoperative morbidity and patient discomfort. Controversy still exists about the best surgical technique for the treatment of the disease in terms of recurrence rate and patient discomfort. METHODS: From January 2000 to November 2003, 100 consecutive age- and sex-matched patients with chronic pilonidal sinus disease were randomized to receive surgical treatment in the forms of either excision and primary closure or rhomboid excision and Limberg flap. Time to return to work and to complete healing were recorded. To evaluate quality of life and patient comfort, all patients were asked to complete a questionnaire including short form 36, Visual Analogue Scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery. RESULTS: Each group was composed of 50 patients. Mean follow-up was 19 months. There was a significant difference between the groups in terms of length of hospital stay (P=.005), time to complete healing (P<.001), time off work (P<.001), and wound infection rate (P=.03). Statistically significant differences were noted between the groups in items of general health perception (71.1+/-11.7 vs 78.2+/-14.1; P=.008), social functioning (87.3+/-32.8 vs 110.4+/-33.8; P=.001), and pain (54.5+/-14.0 vs 67.5+/-18.4; P<.001). Times to sitting on toilet and walking without pain showed significant differences between the groups (P=.006 and P<.001, respectively). The mean postoperative Visual Analogue Scale scores were 6.5+or= 1.7 and 7.4+/- 1.4, respectively (P<.001). CONCLUSIONS: Shorter hospital stay, earlier healing, shorter time off work, lower ratio of complications, lower pain perception, and improved general health perception are the main advantages of te Limberg flap technique in pilonidal sinus surgery. All together, these parameters add to patient comfort and satisfaction after surgical treatment.     

Periprosthetic joint infection—effect on quality of life

Purpose

Relatively little is known about the extent to which periprosthetic joint infections (PJI) affect the patient’s long-term quality of life (QoL). Our study aim was to assess the effect of a periprosthetic infection on our patients’ QoL.

Methods

We collected data retrospectively of patients who had undergone surgery in our institution between 2006 and 2011. To capture their overall QoL, we telephoned the patients who could be reached and asked them the questions on the SF-12 questionnaire.

Results

In 84 patients (53 male, 31 female, 43 TKA and 41 THA), 88 % of the hip infections and 62 % of the knee infections had been successfully treated. The hip infections’ cure rate was significantly higher than that of the knee joint infections. The average SF-12 score was 36.2 points on the physical scale and 52 on the mental scale. The difference in QoL between patients with and without successful infection therapy was not significant, nor did the site of the infection (knee or hip) influence QoL significantly. Comparison of our patients’ QoL data to that from the general population revealed a significant difference in the physical scale but not the mental scale.

Conclusion

From these results QoL is substantially reduced after a prosthetic infection. We did however observe that post-Girdelstone procedure patients or those with an arthrodesis attained an acceptable QoL, and that those methods remain therapeutic alternatives as far as patient-perceived QoL is concerned.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Summary Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.      

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.     

What is the effect of overactive bladder symptoms on woman's quality of life during and after first pregnancy?

OBJECTIVE

To evaluate the effect of overactive bladder symptoms (OAB) on women's quality of life (QoL) during and after the first pregnancy, using self‐reported symptom‐based QoL questionnaires.

PATIENTS AND METHODS

In a prospective cohort study, 474 women were asked to complete four self‐reported questionnaires. Urogenital symptoms were assessed with the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). A women was considered to experience ‘dry’ OAB if she replied positively to the following two questions: ‘do you experience a strong feeling of urgency to empty your bladder?’; and ‘do you experience frequent urination?’. A women was considered to experience ‘wet’ OAB if she replied positively to all of the following questions: ‘do you experience a strong feeling of urgency to empty your bladder?’; ‘do you experience frequent urination?’; and ‘do you experience urine leakage related to the feeling of urgency?’.

RESULTS

In all, 344 (72.6%) women who returned all four questionnaires were included in the analysis. After first childbirth there was a rapid decline in the prevalence of dry OAB (45.2% to 7.9%, P < 0.001). In pregnancy the prevalence of wet OAB increased significantly, but a year after childbirth the prevalence of wet OAB decreased and was similar to that at 12 weeks of gestation (P = 0.289). Women with wet OAB had higher scores on all IIQ domains than those with no OAB symptoms at 36 weeks of gestation. Women with dry or wet OAB all had higher scores on the mobility domain than those with no OAB. The scores on the physical, social and emotional functioning domains were low, suggesting a minimal restriction of lifestyle.

CONCLUSION

OAB symptoms are common during pregnancy; dry OAB had no negative effect on QoL, whereas wet OAB compromised QoL both during and after pregnancy, mainly in the ‘mobility’ and ‘embarrassment’ domains. The urge urinary incontinence symptom in wet OAB seems to profoundly compromise QoL. Apparently, in young mothers with wet OAB, limitations in mobility are especially stressful and these symptoms can be embarrassing.

     

Does thyroid surgery for Graves’ disease improve health-related quality of life?

Purpose

Graves’ disease can induce alterations of the psychosocial well-being that negatively influence the overall well-being of patients. Among the current treatments, surgery has limited indications, and its impact on the health-related quality of life has not been well clarified. The aim of this study was to assess the impact of surgery on the quality of life.

Methods

Fifty-seven patients who underwent total thyroidectomy for Graves’ disease in our surgical unit between April 2002 and December 2009 were administered a questionnaire concerning four issues: organic alterations and clinical manifestations, neurovegetative system disturbances, impairment of daily activities, psychosocial problems. Patients were retrospectively questioned after thyroidectomy about the presence of these symptoms in both the pre and postoperative periods.

Results

There was a significant improvement after surgery in all four areas. Organic manifestations and psychosocial problems had higher average improvements, as did some aspects of the neurovegetative system and difficulties in undertaking daily activities. There were no reports of a worsening of symptoms.

Conclusions

Surgery resolved the hyperthyroidism in 100 % of cases, and was associated with a quality of life improvement of about 70 % in the patients. Surgery can therefore provide an immediate and effective resolution of Graves’ disease, with benefits in health-related quality of life.     

Tremor reduction and quality of life after deep brain stimulation for multiple sclerosis–associated tremor

Background

Tremor is an important cause of disability and poor quality of life amongst multiple sclerosis (MS) patients. We assessed the outcomes of ventral intermediate (VIM) nucleus deep brain stimulation for the treatment of multiple sclerosis (MS)–associated tremor at a single centre in a prospective fashion.

Methods

Sixteen patients (9 female, 7 male) with a mean age of 41.7 years (range 24–59) underwent surgery. The median duration of MS prior to surgery was 6.5 years and median duration of tremor prior to surgery was 4 years. Case selection was by multidisciplinary assessment with carers, therapists, neurosurgeons and movement disorder neurologists. Tremor was scored pre-operatively and at 6 to 12 months post operatively using Bain and/or Fahn–Tolosa–Marin systems. The Euro-Qol 5D tool was used to assess quality of life before and after surgery.

Results

The mean tremor reduction was 39 % with a range between 0 and 87 %. Five of 16 patients achieved at least 50 % tremor reduction and 11 of 16 achieved at least 30 % tremor reduction at last follow up, mean 11.6 months (range 3–80). Tremor was significantly reduced as rated by Bain scores (Wilcoxon matched pairs, Z?=?3.07, p?=?.002) and tended to significance as rated by Fahn scores (Wilcoxon matched pairs, Z?=?1.85, p?=?0.06). Sub-analysis of activities of daily living measures from the Fahn system showed post operative improvement in feeding (statistically significant), hygiene, dressing, writing and working. Mean visual analogue scores (0–100) of patient reported well-being increased from 54.6 to 57.4 post operatively with a trend to significance (Student’s t-test, t?=?1.26, p?=?0.2). Euro-Qol 5D utility values increased following surgery with a trend to significance which was greater in the group with at least 50 % tremor reduction than in those with none or at least 30 % tremor reduction.

Conclusions

VIM DBS may reduce severe, disabling tremor in patients with MS. This tremor reduction tends to be associated with improved quality of life and function in those who respond. Patient reported outcome measures may not correlate with physician rated clinical outcome such as tremor scoring systems and more subtle assessment of these patients is required.     

Remodeling of the proximal femur after upper femoral varus osteotomy for the treatment of Legg-Calvé-Perthes disease

Upper femoral varus osteotomy of the proximal femur without rotation has been the surgical treatment of choice by the senior author (D.S.W.) in 124 cases of Legg-Calve-Perthes disease. There have been no previous studies documenting the nature of the remodeling process after this surgical procedure. The authors analyzed the radiographic changes that occur over time at the osteotomy site and the angle of inclination (neck-shaft angle). Inclusion criteria were a minimum of 2 years of radiographic follow-up. Patient follow-up ranged from 2 to 7 years (average 5.3 years). Goniometric measurements were performed at the osteotomy site as well as on the neck-shaft angle on preoperative, postoperative, and yearly AP radiographs. Results were recorded with reference to the percentage of correction per year. The authors also compared the results of patients younger than 8 years of age (group 1) with those older than 8 years of age (group 2). The average percentage of remodeling at the osteotomy site was 60% at 6 years, with 40% of the correction occurring within the first 2 years. The neck-shaft angle remodeled in a similar fashion: there was approximately two-thirds correction by 7 years, with most correction being evidenced within 3 to 4 years. There was no significant difference in remodeling based on the age of the patient at presentation. In conclusion, radiographically significant remodeling is to be expected after femoral varus osteotomy despite the diseased proximal femoral epiphysis.     

Theatre within 36 h for patients with fracture of the proximal femur: can we deliver?

Background

Proximal femur fractures carry significant levels of morbidity and mortality. Surgical delay is one factor that adversely affects outcome in these patients. In 2010, hospital-income from patients with proximal femur fractures was linked to the surgery being undertaken within 36 h of admission. Can we deliver this target?

Materials and methods

Data from the 2009 National Hip Fracture Database was interrogated and appropriate patients were identified. Patient records were reviewed to identify the reasons for surgical delay. Mortality rates were compared within 36 h and after.

Results

Five-hundred and thirty-two patients were admitted in 2009, 118 (22 %) of them were delayed more than 36 h. Surgery was delayed for a variety of identified reasons. Median time to surgery was 24 h (1–273). Ninety-day mortality for patients treated within 36 h was 12.4 %, but 25 % (P = 0.047) in patients delayed for medical problems.

Conclusions

Not all patients with a fracture of the proximal femur can have surgery within 36 h of their injury. However, we have identified and describe four specific areas that could increase the number of patients who meet this target.     

Health-related quality of life after TAPP repair for the sportsmen’s groin

Background

Sportsmen’s groin (SG) is a clinical diagnosis of chronic, painful musculotendinous injury to the medial inguinal floor in the absence of a groin hernia. Long-term results for laparoscopic inguinal hernia repair, especially data on health-related quality of life (HRQOL), are scant and there are no available data whatsoever on HRQOL after SG. The main goal of this study was to compare postoperative QOL data in the long term after transabdominal preperitoneal hernioplasty (TAPP) in groin hernia and SG patients with QOL data of a normal population.

Methods

This study included all patients (n = 559) who underwent TAPP repair between 2000 and 2005. Forty seven patients (8.4 %) were operated on for SG. We sent out the Short Form 36 Health Survey (SF-36) questionnaire for QOL evaluation. QOL data were compared with data from an age- and sex-matched normal population.

Results

Ultimately, 383 completed questionnaires were available for evaluation (69 % response rate). The mean follow-up time was 94 ± 20 months. In the SG group there were statistically significant differences in three subscales of the SF-36 and the mental component summary measure, showing better results for the SG group compared to the sex- and age-matched normal group data. There were no statistically significant differences between groin hernia patients and the sex- and age-matched normal population.

Conclusion

TAPP repair for SG as well as groin hernia results in good HRQOL in the long term. Results for SG patients are comparable with QOL data of a normal population or even better.     

Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems?

BACKGROUND: Adverse outcomes for patients with isolated hip fracture have been documented when preoperative delay is longer than 48 hours. An efficient system will have the capacity to repair all hip fractures within 48 hours. We hypothesized that in an efficient system, there would be a medical justification for a delay greater than 48 hours. The purpose of this study was to identify the causes and outcome of delay for hip surgery in an efficient system. METHODS: All patients with isolated hip fracture admitted to a regional trauma center from April 1993 to March 2003 were reviewed. Demographics, presence of comorbidity, preoperative delay, complications, and mortality were collected. Univariate and multivariate analysis were carried out. RESULTS: The cohort included 977 patients. Overall mortality was 12.2%. Surgery was performed within 24 hours in 53% of cases and within 48 hours in 87% of cases. The presence of comorbidity partly explained longer (>48 hours) surgical delays. Multivariate analysis revealed that age greater than 65, male sex, and the presence of pulmonary and cardiac comorbid conditions or an active cancer but not surgical delay were associated with mortality and complications. However, surgical delay was associated with longer postsurgical hospital stay, independently of the presence of comorbidity or increasing age. CONCLUSIONS: Preoperative delay does not entail adverse outcomes when the surgery is delayed to allow for treatment of comorbid medical conditions. Preoperative delay is associated with a longer hospital stay. The presence of comorbidity only partly explains preoperative delay and adverse outcomes. A prospective study coding for the severity of comorbid conditions and the justification of the preoperative delay will be required to fully elucidate the link between delay and outcome.     

Sustainability of skill courses for general and visceral surgery—evaluation of the long-term effect

Background  

Surgical skills courses are becoming increasingly popular. This study focuses on their long-term effects.