Pressure sores common after hip operations

We report the incidence of pressure sores in patients operated on for hip fracture or with total hip replacement. Pressure sores were found in 30 and 4 per cent, respectively. Half of the sores appeared within 1 week postoperatively, and more than half healed in the hospital. Most of the sores were found in patients over 80 years of age.

No relation was found between pressure sores and smoking, diabetes mellitus, low hemoglobin, and poor state of nutrition. Patients with pressure sores stayed in the hospital longer and were often discharged to nursing homes.     

Pressure sores common after hip operations

We report the incidence of pressure sores in patients operated on for hip fracture or with total hip replacement. Pressure sores were found in 30 and 4 per cent, respectively. Half of the sores appeared within 1 week postoperatively, and more than half healed in the hospital. Most of the sores were found in patients over 80 years of age.

No relation was found between pressure sores and smoking, diabetes mellitus, low hemoglobin, and poor state of nutrition. Patients with pressure sores stayed in the hospital longer and were often discharged to nursing homes.     

Pressure sores in elderly patients. The epidemiology related to hip operations

The prevalence and onset of pressure sores was studied in 283 patients admitted to a general hospital with either fracture of the proximal femur or for elective hip surgery. Ninety patients developed pressure sores, of which 60 are reported in detail. Most were in women aged 70 or more who had been admitted with hip fractures. The majority of pressure sores started soon after admission, particularly on the day of operation, after which the numbers of new cases decreased. Half the patients had more than one pressure sore and the commonest sites were the sacrum, heels, and buttocks. The mortality in patients with pressure sores was 27% and their mean length of stay in hospital far exceeded that of other patients. The prevention of pressure sores in elderly patients requires more skill and attention than the nurse alone can offer; it demands the help of the whole orthopaedic team.     

Pressure sores and hip fractures

Development of pressure sores during hospital admission causes morbidity and distress to the patient, increases strain on nursing resources, delaying discharge and possibly increasing mortality. A hip fracture in elderly patients is a known high-risk factor for development of pressure sores. We aimed to determine the current incidence of pressure sores and identify those factors which were associated with an increased risk of pressure sores. We retrospectively analysed prospectively collected data of 4654 consecutive patients admitted to a single unit. One hundred and seventy-eight (3.8%) of our patients developed pressure sores. Patient factors that increased the risk of pressure sores were increased age, diabetes mellitus, a lower mental test score, a lower mobility score, a higher ASA score, lower admission haemoglobin and an intra-operative drop in blood pressure. The risk was higher in patients with an extracapsular neck of femur fracture and patients with an increased time interval between admission to hospital and surgery. Our studies indicate that while co-morbidities constitute a substantial risk in an elderly population, the increase in incidence of pressure sores can be reduced by minimising delays to surgery.     

Pressure sores following elective total hip arthroplasty: pitfalls of misinterpretation

OBJECTIVE: To assess the reliability of reporting protocols regarding pressure sores. METHODS: Retrospective data were collected regarding pressure sore rates following total hip arthroplasty operations carried out during 2001 at two orthopaedic units in an NHS hospital (Princess Royal Hospital) and in a local private hospital. RESULTS: Preliminary results presented in audit and interim reports indicated an alarmingly high pressure sore rate across the two sites (17/172 [9.9%] NHS, 23/71 [32.4%] private hospital). On analysis, the data collection system was revealed to be flawed. Grade 1 areas (erythema with no ulceration) were included, leading to a dramatic discrepancy between reported and confirmed pressure sores. Re-analysis showed the confirmed pressure sore rates to be much lower (2.3% NHS, 1.0% private hospital). CONCLUSIONS: This audit suggests that both poor data collection and education lead to inaccurate audit. This may lead to subsequent inappropriate management and inappropriate NHS star ratings.     

Epidural buprenorphine for postoperative analgesia after hip operations

Two groups of 20 patients each were given immediately after hip-operation an epidural injection of 0,15 or 0,3 mg buprenorphine. Effects and side effects are compared with those observed in two groups of patients having the same type of operation, and given either 4 mg of morphine or saline (placebo) by epidural injection. Buprenorphine in both doses produced a shorter duration of analgesia than 4 mg of morphine. In no case did respiratory depression occur. Urinary retention after buprenorphine was barely more frequent than in the placebo group. Nausea and vomiting occurred in 35-45% of patients. We do not see an advantage in replacing morphine by buprenorphine for epidural opiate-analgesia, because the same high rate of nausea/vomiting is associated with a significantly shorter duration of analgesia after buprenorphine. We are convinced that epidural opiate-analgesia is most valuable for postoperative pain relief but should be reserved for selected cases.     

Injury of the common peroneal nerve after cardiothoracic operations

BACKGROUND: To assess incidence, etiology, and clinical relevance of common peroneal nerve injury (CPNI) in patients after cardiothoracic surgery. METHODS: In an 11-year period, CPNI was detected in 39 out of 20,718 patients (0.19%): 38 times after cardiopulmonary bypass (CPB) (38 of 12,726; 0.30%) and in 1 patient after a non-CPB procedure (1 of 7,992; 0.013%). These patients underwent intensive physiotherapeutic treatment. As the majority of CPNI occurred after CPB (97.4%), data of these patients were compared with a 1-year set of 1,032 patients who underwent CPB procedures. RESULTS: Patients with CPNI were older, had a higher percentage of subnormal body weight, and had considerable comorbidity such as peripheral arteriosclerotic disease, diabetes mellitus, and arrhythmias. Follow-up was complete (mean: 5.2 years; 0.4 to 10.7 years). Twenty-eight patients were free of symptoms; 10 patients complained of moderate symptoms, but were not limited in their everyday life; 1 patient still suffers from severe sensorimotor symptoms. CONCLUSIONS: CPNI after cardiothoracic surgery is rare. Duration of the operative procedure, an increased comorbidity, and a subnormal body weight are assumed to have an etiologic impact. Prognosis is mostly good, but early physiotherapeutic treatment is crucial for prognosis.     

Pressure sores: classification and management.

Four grades of pressure can be recognized on the basis of pathophysiology of soft tissue breakdown overlying bony prominences. Management is correlated with the extent of the lesion and ranges from local wound care, turning and systemic support for Grade I and II, to local and radical excision with soft tissue flap closure for the more extensive Grades III and IV.     

Pressure sores and paraplegia: an experimental model

An investigation into the effect of spinal cord transection on pressure sore development is presented and the critical importance of soft tissue atrophy is examined. A technique of spinal laminectomy and spinal cord transection was developed in pigs and shown to have a minimal morbidity rate. Following tissue atrophy, pressure was applied to the paraplegic animals for varying durations. Pressure application was achieved by a computer-controlled application system. The experimental model produced pressure sores extending down to the bone. The resulting tissue damage was assessed, graded, and a pressure-duration curve for paraplegic animals established.     

Partial weight bearing after operations for hip fractures in elderly patients.

Factors affecting a patient's ability to carry out partial weight bearing after operation for hip fracture were studied in 100 patients. Seventy-six were able to do so. Significant factors included the muscle power of the good limbs and the mental state, whereas age, body-weight and type of operation were not significant. Logistical regression analysis showed that it was possible to predict a patient's partial weight bearing potential by simply testing the left hand grip and the 'Set' test score.     

Postoperative analgesia with epidural morphine after hip operations (author's transl)

80 patients undergoing hip surgery under lumbar epidural block have been studied (double blind) for postoperative analgesia. There were 4 groups, of 20 patients each, who received a single epidural injection of 0 mg, 2 mg or 4 mg morphine in 1 ml of saline added to 6 ml bupivacaine 0.5% or 4 mg morphine in 6 ml saline. In the morphine groups analgesia lasted between 37 and 50 hours. No neurological side-effects or severe respiratory depression have was observed; but a significant rise of paCO2 was found. Other side-effects were nausea/vomiting and the need for catheterisation in about 50% of patients. We conclude, that the indications for epidural analgesia with morphine have to be chosen carefully.