Total hip arthroplasties in patients less than forty-five years old

We studied the cases of eighty-one patients (108 total hip arthroplasties), ranging in age from fourteen to forty-five years, at an average of 4.5 years after the index operation and evaluated them with regard to six major factors: age, disease, Charnley category, prior operations, length of time since arthroplasty, and quality of the arthroplasty with regard to cementing technique and component position. After two to five years 78 per cent were satisfactory, but after five years or more only 72 per cent were satisfactory. Patients who were less than thirty years old had poorer results. Good technique yielded 93 per cent satisfactory clinical results. The patients in this study with the worst prognosis for success following total hip arthroplasty were less than thirty years old, had osteonecrosis or osteoarthritis as the primary disease, and had a less than optimum reconstruction. Patients who were alcohol-abusers or who had had a prior hip infection or a prior acetabular cup or femoral hemiarthroplasty also had a poor prognosis. Patients who had the arthroplasty for collagen disease or were thirty years old or older, or both, and had a good technical reconstruction had the best prognosis.     

Mortality after low-energy fractures in patients aged at least 45 years old

BACKGROUND: Fractures sustained in low-energy injuries are recognized as a major public health issue, although, with the exception of proximal femoral fractures, little is known about the subsequent mortality rates. The aim of this study was to compare the survival rates of a population of individuals who sustained 3 types of low-energy fractures with age-matched cohorts from within the same population. METHODS: Between January 1988 and December 1999, data were prospectively gathered from all inpatient and outpatient fracture cases at a single trauma unit. During this time, 18,019 patients sustained low-energy fractures of the proximal femur, proximal humerus, or wrist. Survival analysis using the life table method was performed and hazard ratios calculated for risk of mortality when compared to general population controls within the first year postinjury, between the second and fifth years postinjury, and between the sixth and tenth years postinjury. The effects of various social, physical, and mental health parameters on survival were also analyzed using a Cox proportional hazards model. RESULTS: The patients who sustained proximal femoral fractures were older and significantly more physically and mentally impaired than the patients who sustained wrist fractures. The demographic features of the proximal humeral fracture cohort were intermediate between these 2 groups. The mortality was high in all age groups following proximal femoral and proximal humeral fractures, though the relative risk of death, when compared to age-matched population controls, decreased with increasing age at fracture. The risk of death in these groups was greatest in younger individuals and in the first year postinjury. The wrist fracture population had similar or enhanced survival when compared to age-matched population controls. The mortality after fracture was independently predicted by age at fracture, male gender, and use of walking aids, for all 3 fracture groups (P < 0.05), and additionally by level of social dependence in the proximal femoral fracture group (P < 0.05). Level of evidence: level one, prospective cohort study. CONCLUSIONS: There is prolonged risk of premature mortality seen in both proximal femoral and proximal humeral fracture groups in the younger age cohorts, possibly as a result of concomitant medical comorbidities contributing to their premature deaths. Elderly patients sustaining proximal femoral fractures, despite high risk of mortality in the first year after injury, have survival approaching those of the general population in the longer term. Elderly patients who sustain wrist fractures have consistently better survival rates than the general population. This group of patients may be physiologically more robust than their age-matched peers in the general population.     

McKeever hemiarthroplasty of the knee in patients less than sixty years old

BACKGROUND: Knee arthritis in the young patient is a challenging problem that may necessitate surgical treatment. We continue to perform hemiarthroplasty with a metallic tibial implant in selected young patients who, for various reasons, are not candidates for osteotomy, unicompartmental arthroplasty, or total knee arthroplasty. The purpose of the present study was to determine the minimum twelve-year results of this procedure in young patients. METHODS: The original study group consisted of a consecutive series of twenty-four patients (twenty-six knees) who were managed with McKeever tibial hemiarthroplasty for the treatment of unicompartmental osteoarthritis of the knee. All patients were younger than sixty years of age at the time of the index procedure (average age, 44.6 years). During the study period, two patients died and one was lost to follow-up, leaving twenty-one patients (twenty-three knees) available for review. All patients were followed clinically for a minimum of twelve years or until revision. Knee Society knee and functional scores and Tegner scores were determined, and seven of the ten implants were evaluated radiographically. RESULTS: Thirteen knees were revised at an average of eight years after the index procedures. All thirteen knees had an uncomplicated revision to either a unicompartmental arthroplasty or total knee arthroplasty. Ten retained implants were available for clinical review after an average duration of follow-up of 16.8 years. The mean Knee Society knee scores, functional scores, and Tegner scores, available for nine of these ten knees, were 80, 97, and 4.2, respectively. CONCLUSIONS: We believe that the McKeever tibial hemiarthroplasty continues to be a reasonable surgical option for patients who are not candidates for osteotomy and are too young or too active for a unicompartmental or total knee arthroplasty.     

80岁以上髋部骨质疏松性骨折患者院内死亡分析

目的 探讨高龄髋部骨质疏松性骨折患者院内死亡原因及其影响因素.方法 对62例80岁及以上髋部骨折患者的临床资料进行回顾性分析,包括并发疾病、美国麻醉医师协会评分(ASA评分)、骨折部位、死亡原因,统计年龄、超声心动图左心室射血分数、血气分析、血肌酐、血红蛋白等各项检查指标.结果 7例入院后因全身情况迅速恶化未手术而死亡.排除了术后死亡的3例(去除手术影响因素),存活组52例,比较两组临床数据发现ASA评级与病死率显著相关(P =0.019),患者并发肺炎、心脑血管疾病、肾功能不全以及左心室射血分数小于45％都增加髋部骨折后的病死率(P=0.013,P=0.044,P=0.048,P=0.030),80岁以上老年人髋部骨折后的院内病死率与年龄、性别、骨折类型、入院时血红蛋白水平、老年谵妄和糖尿病没有显著相关性.结论 高龄髋部骨折患者围手术期需注意预防和治疗呼吸系统、心脑血管系统疾病,同时注意调整肾脏等器官的功能,严格把握手术适应证,减少住院期间的并发症和降低病死率.     

Liver transplantation in patients over sixty years of age.

BACKGROUND: Although some centers have reported very good patient and graft survival in liver allograft recipients, reports from both North America (United Network of Organ Sharing) and Europe (European Liver Transplantation Registry) have failed to confirm this. AIM: We have reviewed our experience of liver transplantation in older recipients and compared their clinical outcome to a younger group. METHODS: Retrospective analyses were conducted on 875 consecutive adult patients undergoing liver transplantation for chronic liver disease, between 1990 and 1999. Group I consisted of patients under 60 years of age (n=701; 80.2%) and group II of patients over 60 years (n=174; 19.8%). RESULTS: The proportion of older patients transplanted increased from 10.15% between 1990-1991 to 20.85% (1997-1999). Actuarial graft survival at 1, 3, and 5 years was 78%, 74%, and 69% and 78%, 73%, and 66% for groups I and II, respectively (P=0.49). The overall actuarial patient survival tended to be better in the younger group (1-, 3-, and 5-year survival of 83%, 79%, and 76% for group I and 81%, 75%, and 69% for group II (P=0.07). Crude mortality probability shows a stable trend until 45 years, a gradual increase in mortality between 45 and 60 years, and then the risk of death is accelerated. The same analysis shows the risk of death is between 1.5 and 2 times greater in Child C patients; this is greater in patients aged more than 66 years. CONCLUSION: There is no statistically significant difference in patient or graft survival in patients aged over 60 compared to younger recipients. However, when age is assessed as a continuous variable, an adverse effect of older age is seen on outcome and this effect is more marked in sicker patients.     

Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987.

Large epidemiologic analyses of cardiovascular injuries have been limited to studies of military campaigns compiled from many surgeons working in many hospitals with variable protocols. A detailed civilian vascular trauma registry provides a unique opportunity for an epidemiologic evolutionary profile. During the last 30 years in a single civilian trauma center directed by a consistent evaluation and treatment philosophy, 4459 patients were treated for 5760 cardiovascular injuries. Eighty-six per cent of the patients were male, and the average age was 30.0 years. Penetrating trauma was the etiology in more than 90% (GSW,51.5%; SW,31.1%; SGW,6.8%). All other injuries were iatrogenic or secondary to blunt trauma. Truncal injuries (including the neck) accounted for 66% of all injuries treated, while lower extremity injuries (including the groin) accounted for only 19%. Injuries to the abdominal vasculature accounted for 33.7% of the injuries. One thousand fifty-seven patients had 2 or more concurrent vascular injuries, and 32 patients had 4 or more separate vascular injuries. The 27 patients-per-year average of the early 1960s has risen to a current average of 213 patients per year. Economic and population factors influenced wounding agents and injury patterns during the evaluation period. This extensive civilian series presents epidemiologic profiles that are distinctly different from military reports and serves as a guide for current trauma center and health planners.     

Kidney transplantation in patients aged sixty years and older

Outcomes of renal transplantation were reviewed for 26 transplants performed in 25 patients 60 years of age or older between 1985 and 1989. Three grafts were from family donors and 23 were from cadaver donors. Twenty-one were first transplants and five were retransplants. Cyclosporine was used as primary immunosuppression and azathioprine and prednisone were administered to most patients. Overall patient and graft actuarial survival rates were 79% and 71%, respectively, at both 1 and 3 years. Patients (n = 14) free of both diabetes and cardiac disease (low risk) had 1- and 3-year patient and graft survival rates of 91% and 84%, respectively. Conversely, high-risk patients (n = 12) had patient and graft survival rates at 1 and 3 years of 67% and 58%, respectively. Early deaths (less than or equal to 6 months) were caused by sepsis (two patients) or cardiac events (three patients), and four of the five were in high-risk patients. Irreversible rejections and serious infectious complications were not as common as steroid-induced diabetes, which occurred in five patients. This experience suggests that kidney transplantation can be done safely and successfully in patients older than 60 years of age and should be the treatment of choice for low-risk patients in this category.     

老年患者的肝移植

目的探讨老年患者接受肝移植治疗的特点并分析其术后生存时间。方法2000年1月至2005年8月,共施行18岁以上成人首次肝脏移植1424例。将年龄≥60岁的211例受者分为老年组,其余的1213例受者为成年组。统计分析两组患者术前、术中指标及术后生存时间。结果单因素分析比较发现,老年组患者术前合并消化道出血的比例及术前血清胆红素总量、凝血酶原时间低于成年组,手术过程和无肝期时间较成年组略短。老年组术后急性排斥反应发生率(13.27%)和再次移植率(0.95%)低于成年组(19.37%,P=0.035;3.96%,P=0.028)。成年组术后6个月、1年、2年、3年、4年及5年累积生存率分别为88.67%、85.52%、77.53%、75.52%、73.77%和70.9%,老年组术后6个月、1年、2年及4年累积生存率分别为87.91%、83.42%、78.70%和40.14%,两组生存时间比较,差异无统计学意义(P=0.697)。对患者术后生存时间采用Cox比例风险模型进行多因素分析,影响肝移植术后生存时间的危险因素是:原发恶性肝病(P=0.000)、合并肝肾综合征(P =0.021)、供肝热缺血时间(P=0.046)以及术后发生感染(P=0.000)。结论高龄不再是肝移植的禁忌证,合理筛选适宜手术的老年受者可获得与成年受者相近的术后存活时间。     

Unicompartmental knee arthroplasty in patients sixty years of age or younger

BACKGROUND: Unicompartmental knee arthroplasty has been used to treat elderly, low-demand patients, but the literature is sparse regarding the use of this procedure for younger, active patients. The purpose of the present retrospective study was to evaluate the results of unicompartmental knee arthroplasty in younger, more active patients. METHODS: Forty-one patients underwent forty-six consecutive unicompartmental knee arthroplasties with use of the Miller-Galante system between 1988 and 1996. All of the patients were sixty years of age or younger and all were physically active. The Hospital for Special Surgery knee score and the University of California at Los Angeles activity assessment were used to rate the function and to determine the activity level of each patient, respectively. Serial radiographs were used to evaluate the status of prosthetic fixation, femorotibial alignment, and the progression of arthrosis in the unreplaced compartment. Long-term survivorship was calculated with use of Kaplan-Meier analysis. RESULTS: The mean duration of follow-up was eleven years. Of the forty-five knees that were available for follow-up, three had been revised. The Hospital for Special Surgery score was excellent for thirty-nine (93%) of the remaining forty-two knees and good for three. The University of California at Los Angeles activity assessment score was 6.6 +/- 1.4 for the knees in which the original prosthesis had been retained and 7.3 +/- 1.5 for those in which it had been revised. Two asymptomatic patients had revision of a modular tibial component because of substantial radiographic evidence of polyethylene wear; one of these patients had exchange of the polyethylene insert and the tibial tray, and the other had exchange of the polyethylene insert only. A third patient underwent revision total knee arthroplasty because of continuing knee pain and a progressive tibial radiolucent line that was >2 mm in width. The average postoperative femorotibial alignment was 5 degrees of valgus. Nine knees had progression of arthritis in the unresurfaced compartment; none of these knees were revised, and none of the patients had deterioration in the Hospital for Special Surgery score. Kaplan-Meier analysis demonstrated an eleven-year survivorship of 92%. CONCLUSIONS: At an average duration of follow-up of eleven years, unicompartmental knee arthroplasty was associated with pain relief and excellent function in a cohort of patients who had been sixty years of age or younger and active at the time of surgery.     

Herniorrhaphy in patients aged 80 years or more. A prospective analysis of morbidity and mortality.

OBJECTIVE--To find out the morbidity and mortality after repair of groin hernias in patients aged 80 years or more, and to identify factors that add to the risk of hernia repair. DESIGN--Prospective open study. SETTING--All general surgical departments in Ringk?bing County, Denmark. SUBJECTS--All 39 patients aged 80 years and over who were admitted with hernias during a one year period (1990). OUTCOME MEASURES--Morbidity and mortality. RESULTS--Three patients refused operation, and of the remaining 36, 15 (42%) were admitted as emergencies (5 of whom were already waiting for elective repair of their hernias). The median age was 84 years (range 80-90) and 23 (64%) were men, 31 patients had inguinal hernias, 4 had femoral hernias, and one an obturator hernia. There were six major and two minor complications after 14 emergency operations (57%), and one minor complication after 22 elective operations (5%, p = 0.0007). Two patients died, both after emergency operations (14%). CONCLUSION--Elective hernia repair can be carried out safely even in the presence of serious coexisting disease, and emergency hernia repair carries a high risk of complications even in the absence of coexisting disease.     

Musculoskeletal manifestations of amyloidosis. A review of 83 patients on haemodialysis for at least 10 years

Long-term regular haemodialysis for chronic renal failure is associated with amyloidosis. In this condition excess amounts of the unexcretable plasma protein beta-microglobulin are laid down in tendons, joints and bones. Amyloidosis presents with various musculoskeletal disorders only after several years of dialysis. We reviewed 83 patients who had been dialysed for at least 10 years. The commonest complaint was severe joint pain in the absence of radiological changes of arthritis (41%), the shoulders usually being the most affected (33%). Carpal tunnel syndrome had developed in 26 patients, and was bilateral in 14 of them; at operation the presence of amyloid was confirmed. Six of these patients had recurrent symptoms after a further two to three years and required another decompression. Other manifestations of amyloidosis included trigger finger, flexor tendon contracture, spontaneous tendon rupture and pathological fracture through amyloid bone cysts. The frequency of symptoms was proportional to the duration of dialysis: all 13 patients on dialysis for over 20 years were affected. Symptoms developed earlier in older patients.     

Renal transplantation in patients 65 years old or older.

Between January 1982 and August 1989, cadaveric renal transplantation was performed in 22 patients 65 years old or older. Mean recipient age was 68 years (range 65 to 73 years). There were 17 men and 5 women. Additional risk factors included retransplantation (3 patients), high (greater than 30%) panel reactive antibody (4) and diabetes (1). All patients received cyclosporine as part of the immunosuppressive regimen. The 3-year actuarial patient and allograft survival rates were 89% and 71%, respectively. There were 6 graft losses due to chronic rejection (2 patients), renal vein thrombosis (1), myocardial infarction (1), withdrawal of immunosuppression because of sepsis (1) and primary nonfunction (1). Of the 16 patients with a functioning graft 12 currently have a serum creatinine of less than 2.0 mg./dl. These results suggest that cadaveric renal transplantation is an acceptable form of treatment for patients older than 65 years with end stage renal disease.     

Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

OBJECTIVE: To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group. SUBJECTS AND METHODS: Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting. RESULTS: In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE. CONCLUSION: At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.     

Burns in patients over 60 years old: epidemiology and mortality.

Epidemiology and mortality among burn patients over age 60 years who were admitted to the Burn Centre of La Fé Hospital (Valencia, Spain) between 1 January 1988 and 1 January 1991 have been studied. A total of 443 patients (7.8 per cent of all presenting patients) were hospitalized during this 3-year period; of these, 69 (15.5 per cent) were over 60 years old. There were 40 females and 29 males (mean age, 72.2 years). Mean burn area was 21.6 per cent of total body surface, and the most commonly involved regions were the lower limbs (81 per cent). Fire flames were the most common cause of burns (65.2 per cent) and produced the most extensive lesions. Eight-five per cent of the accidents occurred at home, and winter was the season of highest incidence. Patient mortality was 33.3 per cent, the most common causes of which were hypovolaemic shock during the first 24 h and pneumonia in the later stages.     

55岁以上原发骨质疏松性骨折患者特征及趋势分析

目的分析55岁(含)以上股骨近端骨折、脊柱骨折和桡骨远端骨折患者特征及其随时间变化的趋势。方法以国际疾病分类ICD-10为检索标准,回顾性收集55岁(含)以上股骨近端、脊柱和桡骨远端三类骨折住院患者信息,本文主要是对其年龄、性别及时间分布特征进行描述和分析。结果股骨近端骨折的发生占比随年龄递增(P0.001),桡骨远端骨折、脊柱骨折的发生均与之相反,随年龄占比递减(P0.001,P=1.29*10~(-35))。股骨近端骨折峰值年龄增加,近三年峰值年龄位于80～85岁间,男女趋势一致;桡骨远端骨折峰值年龄亦增加,最新峰值位于60～65岁之间,女性趋势与之一致,男性则变化不显著。脊柱骨折年龄峰值随时间发生偏移,但趋势不显著,整体由75岁降低到65岁,其中男性由75～79岁偏向60～64岁,女性由70～75岁偏向65～70岁,男性降低幅度较大。2010年至2018年三类骨折平均性别比变化分别为(女:男)股骨近端骨折2.13∶1～2.43∶1,脊柱骨折为3.37∶1～3.77∶1,桡骨远端骨折为3.76∶1～4.96∶1。结论需重点关注高龄老人骨折诊疗,尤其是股骨近端骨折。女性骨质疏松性骨折仍占临床主导地位,但中老年男性骨质疏松问题亦不容忽视,随着其特异性病因的明确,建议将其纳入诊疗指南的范畴。