Femoral neck fractures in patients receiving long-term dialysis

The morbidity and mortality of 11 femoral neck fractures were analyzed to compare operative and conservative management of femoral neck fractures in dialysis patients. All fractures occurred in older men with severe cardiac, pulmonary, gastro-intestinal, and neurologic conditions and with advanced renal osteodystrophy. Six of the seven operated patients survived the surgery and achieved varying degrees of ambulation. Stability of the operated hip was excellent in each case. Post-operative complications included transient confusional state related to narcotics, pneumonia, decubitus ulcers, and severe hypoalbuminemia. All four patients who were managed conservatively died from complications of the fracture. Progressive deterioration was noted in each nonoperated patient, with confusion caused by narcotics and analgesics, pneumonia, hepatic coma, decubitus ulcers, severe depression, and severe hypoalbuminemia. Therefore, operative management was superior to conservative management for femoral neck fractures of patients receiving chronic dialysis with multiple medical problems and advanced renal osteodystrophy. Narcotics must be used with great caution, and efforts should be directed toward prevention of malnutrition and decubitus ulcers.     

Internal fixation of femoral neck fractures in Parkinson's disease 32 patients followed for 2 years

32 patients, suffering from Parkinson's disease, had internal fixation of femoral neck fractures. In 24 displaced fractures, 6 nonunions and 3 segmental collapses were seen; and in 8 undisplaced fractures, 1 case of segmental collapse was diagnosed. Healing complications were thus seen in one third. Total hip replacement for healing complication was performed in 3 of 32 patients. 9 patients died within 2 years. No difference in the rate of healing or mortality was detected compared with hip fracture patients without Parkinson's disease.

Our study does not support primary arthroplasty for femoral neck fracture in patients with Parkinson's disease.     

Neglected bilateral femoral neck fractures in a patient with end-stage renal disease before chronic dialysis.

Bilateral femoral neck fractures are rarely reported in patients with end-stage renal disease before chronic dialysis. We report on a 39-year-old woman with neglected bilateral femoral neck fractures, who presented with severe uremic complications prior to chronic dialysis. Three years before admission, she had injured herself in a trivial slip with subsequent bilateral hip pain. She had progressively waddled since then. Pelvic X-ray taken after admission revealed bilateral femoral neck fractures. Bilateral hip hemiarthroplasties were subsequently performed. Displaced femoral neck fractures were found intraoperatively. Pathologic findings and results of examinations supported the coexistence of osteoporosis and high turnover renal osteodystrophy, rendering this woman at high risk of bilateral femoral neck fractures. Therefore, preventing a simple fall or trivial accident and treating renal osteodystrophy and osteoporosis are paramount in patients with chronic renal failure even before the start of dialysis therapy. We also emphasize the need to seek any possible underlying metabolic bone disease once a patient presents with unusual fractures.     

人工髋关节置换术治疗股骨颈骨折合并帕金森病的疗效

目的探讨对合并帕金森病的股骨颈Garden Ⅲ或Ⅳ型骨折患者进行关节置换的临床疗效及安全性。方法本组自2006年3月至2009年10月收治股骨颈骨折合并帕金森病患者29例,除2例70岁以下的Ⅱ期患者采用全髋关节置换以外,其余27例均采用人工双极股骨头置换术。所有病例均采用后方入路进行手术,其中17例行内收肌切断术。结果 29例患者中2例分别于术后7个月和9个月死亡。17例帕金森病Ⅱ期和Ⅲ期患者术后站立时间平均为11d,而Ⅳ和Ⅴ期平均下地站立时间为术后21d。并发症中肺部炎症多见,有8例出现咳痰无力和肺炎等。发生脱位1例。术后Harris评分优5例,良13例,可7例,差4例。结论对于合并帕金森病的股骨颈Garden Ⅲ或Ⅳ型骨折患者来说,人工双极股骨头置换是一种较好的选择。但此类患者手术风险大,术后康复难以配合,术后并发症及功能恢复不良发生率较高。     

Internal fixation of femoral neck fractures in Parkinson's disease. 32 patients followed for 2 years

32 patients, suffering from Parkinson's disease, had internal fixation of femoral neck fractures. In 24 displaced fractures, 6 nonunions and 3 segmental collapses were seen; and in 8 undisplaced fractures, 1 case of segmental collapse was diagnosed. Healing complications were thus seen in one third. Total hip replacement for healing complication was performed in 3 of 32 patients. 9 patients died within 2 years. No difference in the rate of healing or mortality was detected compared with hip fracture patients without Parkinson's disease. Our study does not support primary arthroplasty for femoral neck fracture in patients with Parkinson's disease.     

Intertrochanteric and femoral neck fractures in patients with parkinsonism

Thirty-eight patients with parkinsonism were reviewed after fracture of the hip. The 12-month mortality rate was the same as in other patients with hip fractures but without parkinsonism. However, the morbidity was higher-with loss of independent existence, loss of ambulation and an increased risk of dislocation of the endoprosthesis.     

The unresolved problem of beta-2 microglobulin amyloid deposits in the intervertebral discs of long-term dialysis patients

Background

Dialysis-related destructive spondyloarthropathy caused by beta-2 microglobulin (β2M) amyloid deposits in intervertebral discs is a major burden for patients undergoing long-term dialysis. This study aimed to quantify the presence of β2M amyloid deposits in the intervertebral disc tissue of such patients and analyze whether there was a significant correlation between β2M accumulation and the duration of dialysis.

Methods

Two groups of patients who had undergone surgery for degenerative spinal pathologies were selected: the dialysis group (n?=?29) with long-term dialysis and the control group (n?=?10) with no renal impairment. Tissue sections were prepared from specimens of intervertebral disc tissue obtained during spinal surgery and analyzed via histological staining, including immunohistochemistry (IHC) and Congo red.

Results

There was a statistically significant multifold increase of β2M expression in the disc tissue of long-term dialysis patients when compared to non-dialysis patients, as shown by both IHC (0.019?±?0.023 μm² vs. 0.00020?±?0.00033 μm², respectively; p?=?0.012) and Congo red staining (0.027?±?0.041 μm² vs. 9.240?×?10^?5?±?5.261?×?10^?5 μm², respectively; p?=?0.047). We also note a moderate strength positive correlation between the duration of dialysis and positive IHC (r?=?0.39; p?=?0.015) and Congo-red staining (r?=?0.42; p?=?0.007).

Conclusions

The problem of β2M amyloidosis in long-term dialysis patients remains unresolved even with predominant use of high-flux dialysis membranes. This highlights the insufficiency of current dialysis modalities to effectively filter β2M.

     

Biochemical characterization of serum and urinary beta 2 microglobulin in end-stage renal disease patients.

Since the identification of beta 2 microglobulin (beta 2-M) in haemodialysis-associated amyloidosis, the biochemical characterization of the different forms of beta 2-M has been sought by several groups. New beta 2-M isoforms (pI 5.1 and lower) have been identified in amyloid deposits, and it has been suggested that they are of pathogenetic importance. The finding of N-terminal proteolysed beta 2-M in amyloid deposits prompted the hypothesis that proteolysis would render beta 2-M more amyloidogenic. Finally, a 'novel beta 2-M' (pI 5.2) with a single amino acid replacement (Asn by Asp at position 17) has been reported as possibly specific for patients with dialysis associated amyloidosis, and consequently proposed as 'the amyloidogenic' form. We purified beta 2-M from serum of a newly haemodialysed patient and from urine of a transplanted patient in the early recovery period. Both patients were clinically amyloid free. Three pure isoforms were obtained from serum (pI 5.7, 5.3, and 5.1) and only two from urine (5.7 and 5.3). Further purification of each isoform was obtained by HPLC in a C4 column. Sequence analysis showed that all isoforms had an intact N-terminus. Tryptic digestion of the serum isoforms was performed after alkylation with iodoacetic acid and the peptides were isolated by HPLC in a C18 column. The 5.3 and 5.1 isoforms had identical peptide patterns with the appearance of an early peak missing in the 5.7 form. The sequence of this peptide showed a replacement of the D 42 (Asp 42) by N (Asn) after K41 (Lys 41).(ABSTRACT TRUNCATED AT 250 WORDS)     

Fractures of the femoral neck in children: long-term follow-up in 62 hip fractures

In this retrospective study, we evaluated the characteristics of 103 femoral neck fractures in 102 children seen our department between 1978 and 1994. In order to evaluate the correlation between the chosen procedure and complication risks, we further reviewed the late treatment results of 62 fractures in 61 children of the series whom we had followed for a minimum of 8 years. The ages of these children at the time of injury ranged from 2 to 14 years (average 10.2 years). Sixty-three hips were available for clinical and radiographic follow-up at a minimum of 8 years (mean 14 years). Overall, 67.2% radiologically good results were obtained. Complications were coxa vara in five (8%), avascular necrosis in nine (14.5%), premature epiphysis fusion in five (8%), coxa valga in two (3.2%), non-union in one (1.6%), limb shortening in seven (11.3%), and arthritic changes in two (3.2%). Our long-term follow-up revealed that the type of treatment influences the complication rate more than do the characteristics of the fracture itself, and that the end result cannot be satisfactorily determined until after physeal closure.     

Factors predicting healing complications in femoral neck fractures: 138 patients followed for 2 years

We have previously studied the radiographic outcome of femoral neck fracture osteosynthesis with either two hook-pins or a four-flanged nail performed by a small group of surgeons with special interest in the methods. In 138 femoral neck fractures a backwards stepwise logistic regression analysis was used to study the significance of preoperative fracture-related factors, intraoperative factors and the osteosynthesis. The development of non-union/re displacement and segmental collapse of the femoral head was influenced by fracture displacement (P 0.001) and method of osteosynthesis (P 0.007). The postoperative scintimetric ratio was influenced by the method of osteosynthesis (P 0.0003), fracture displacement (P 0.004) and by the presence of a posterior fragment (P 0.03).

Reduction of the fracture and positioning of the osteosynthesis were to a large extent within the accepted limits. This may explain why the previously well documented negative effects of malpositioning of the osteosynthesis and inferior reduction were not demonstrated to influence the rate of healing-complications. We conclude that neither patient age, sex nor preoperative fracture variables, with the exception of the extent of fracture displacement, can be used to predict radiographic healing-complications in femoral neck fractures.     

Ununited ipsilateral femoral neck and shaft fractures: treatment of 16 patients

Introduction Ununited ipsilateral femoral neck and shaft fractures are very rare, and their treatment is very complicated. Until now, no single treatment method has been recommended in the literature.Materials and methods Eighteen patients sustained femoral shaft fractures, which were treated with reamed intramedullary nails but remained ununited. Concomitant, ipsilateral femoral neck fractures were neglected for 2–16 months (median 4 months). The neck fractures were treated by subtrochanteric valgus osteotomy with sliding compression screw stabilization, and the shaft fractures by dynamic compression plating with supplementary cancellous bone grafting. Postoperatively, ambulation with protected weight-bearing was encouraged as early as possible.Results Sixteen patients were followed up for at least 2 years (range 2–7 years), and all fractures healed. The neck fracture healed at 3.7±0.6 months (p<0.001), the osteotomy site at 5.3±0.9 months, and the shaft fracture at 5.6±1.0 months (p=0.07). All patients could walk without aids. Complications included one osteonecrosis of the femoral head (6.3%), which was followed up regularly without further treatment.Conclusion The described technique provided a high union rate with a low complication rate. In addition, the surgical procedure was relatively simple. Therefore, it might be considered for all indicated cases.     

Serum beta2 microglobulin (beta2MG) level is a potential predictor for encapsulating peritoneal sclerosis (EPS) in peritoneal dialysis patients

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is a serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). The aim of this study was to find a predictor for EPS. METHODS: Patients with EPS who were detected by a historical cohort study using clinical data of 219 CAPD patients at our hospital. We recruited 25 patients with EPS who were compared with the patients without EPS who were matched for age and dialysis period as controls. Differences between the two groups (non-EPS group and EPS group) with respect to age, gender, primary disease, dialysis period, serum urea nitrogen, serum creatinine, beta2MG, CRP and PET (peritoneal equilibration test) category (determined by the peritoneal function testing) were analyzed. RESULTS: According to multiple regression analysis, a high beta2MG level was an independent risk factor for EPS (odds ratio 1.162, 95% confidence interval 1.026 - 1.317, p = 0.018). Other clinical markers did not show positive significance. A ROC (receiver operating characteristic) curve was prepared to evaluate the suitability of I(2)2MG measurement as a screening test. The sensitivity was 64% and the specificity was 80% when a beta2MG level of 37.0 mg/dl was taken as the cut-off value. The odds ratio for occurrence of EPS was 8.8 when beta2MG level was in the range of 35 - 40 mg/dl, 13.5 when I(2)2MG level was > 40 mg/dl and 1 when beta2MG level was < 30 mg/dl. CONCLUSION: These findings suggest that beta2MG is useful as a screening test for the onset of EPS, and that beta2MG and accumulation of middle-molecular uremic substances may be related to the pathophysiology of EPS.     

腹膜透析患者β 2微球蛋白水平变化及其影响因素

目的:分析持续不卧床腹膜透析患者血清β 2微球蛋白水平与临床指标的关系,探讨β 2微球蛋白升高的相关危险因素。 方法:本研究为回顾性研究,选取2015年1月至2019年8月于东莞东华医院血液净化科接受腹膜透析的患者,根据β 2微球蛋白三分位数水平分为3组,比较其临床和实验室...     

Renal excretion and cyst accumulation of beta 2microglobulin in polycystic kidney disease

To determine the extent to which proximal tubule function is altered beta 2microglobulin (beta 2m), creatinine and Na were measured in serum, urine and cyst fluid of patients with autosomal dominant polycystic kidney disease and various degrees of renal insufficiency. Fractional excretion (FE beta 2m) was 0.11 +/- 0.03% in six normal subjects and 0.13 +/- 0.05% in nine patients with serum creatinine levels less than 1.6 mg/dl. In five patients with serum creatinine levels above 3.0 mg/dl, FE beta 2m was elevated (range 3.5 to 196%) and serum levels were higher than normal (30,600 +/- 6,910 micrograms/liter vs. 1,268 +/- 111). In seven patients beta 2m levels in 33 proximal cysts (cyst/serum Na greater than 0.8) equalled those in serum (cyst/serum beta 2m 0.98 +/- 0.20), whereas in 21 distal cysts (cyst/serum Na less than 0.4) beta 2m was less than in serum (cyst/serum beta 2m 0.17 +/- 0.07). Analysis of fluid in two patients with polycystic kidney nephrectomy several weeks posttransplant indicated that proximal cyst epithelium is permeable to beta 2m, but less so than to creatinine or urea. These studies show that proximal cysts cannot develop or maintain gradients for beta 2m, whereas distal cysts maintain low levels of the protein despite end-stage renal failure. The normal FE beta 2m values in nonazotemic autosomal dominant polycystic kidney disease patients and the low distal cyst levels of beta 2m in end-stage kidneys indicate that the cystic proximal nephrons do not contribute appreciably to the final urine.(ABSTRACT TRUNCATED AT 250 WORDS)