Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment.

A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.     

Quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility

The purpose of this study was to investigate the quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility. A retrospective chart review was performed on 372 consecutive children who underwent orthopaedic surgery for a diagnosis of fracture, infection, slipped capital femoral epiphysis (SCFE), or compartment syndrome during a 22-month period at the authors' facility. Of the 372 children, 142 children (38%) first received medical care elsewhere; these are the subjects of this study. Before being seen at the authors' institution, 27 children (19%) had a problem in treatment or diagnosis and 18 (13%) had a delay in diagnosis or treatment of greater than 48 hours. Problems in diagnosis included five children with unrecognized open fractures, four of whom did not receive antibiotics; six children with missed SCFE, five of whom were not made non-weight-bearing; and six missed closed fractures. Delay in treatment occurred for 15 fractures, with a mean delay of >7 days until surgical treatment. Insurance status and primary language of the family were not associated with problems or delays in treatment. Overall, 32% of children undergoing time-sensitive orthopaedic surgery at a tertiary pediatric center had problems or delays in the medical care they received before transfer.     

Clinical implications of anatomical wear characteristics in slipped capital femoral epiphysis and primary osteoarthritis

BACKGROUND: This study compares the wear characteristics in slipped capital femoral epiphysis (SCFE) with those of primary osteoarthritis (OA) in adult patients with advanced arthritis. METHODS: One hundred femoral heads and proximal neck specimens were studied from SCFE patients (16 hips) and from primary OA (84 hips) patients undergoing total hip arthroplasties (THA). Grade 4 chondromalacia was plotted on a 2-dimensional (2-D) paper grid. Computer tomographic scans were used to create 3-D models of the femoral head and neck to trace the wear patterns. RESULTS: The SCFE group was characterized by (1) loss of neck-head offset, (2) acetabular neck impingement, and (3) loss of superior peripheral articular cartilage adjacent to superior neck. Whereas the primary OA group showed (1) preservation of head-neck offset, (2) absence of acetabular neck impingement, and (3) preservation of superior peripheral articular cartilage. The 3-D modeling in SCFE specimens demonstrated acetabular impingement on the superior lateral femoral neck causing the femur to externally rotate with flexion. The SCFE patients undergoing THA on average were 11 years younger than those with primary OA. The study strongly suggests that the abnormal rotation of the femoral head in SCFE patients causes thinner superior lateral articular cartilage on the femoral head to articulate with the acetabulum. The pistol-grip deformity of the proximal femur in the SCFE group results in hip impingement, which explains why hip flexion and internal rotation can be restricted. CONCLUSIONS: There was a premature development of advanced OA of the adult hip joint in SCFE patients. This was associated with hip impingement caused by loss of the head-neck offset and reorientation of the articular cartilage of the femoral head. Unless the femoral head is redirected in patients with SCFE, the benefits of limited hip preservation debridement procedures are not expected to delay the onset and progression of arthritis. LEVEL OF EVIDENCE: Prognostic study.     

Effect of weekend admission on geriatric hip fractures

BACKGROUND The care discrepancy for patients presenting to a hospital on the weekend relative to the work week is well documented. With respect to hip fractures, however, there is no consensus about the presence of a so-called "weekend effect". This study sought to determine the effects, if any, of weekend admission on care of geriatric hip fractures admitted to a large tertiary care hospital. It was hypothesized that geriatric hip fracture patients admitted on a weekend would have longer times to medical optimization and surgery and increased complication and mortality rates relative to those admitted on a weekday.AIM To determine if weekend admission of geriatric hip fractures is associated with poor outcome measures and surgical delay.METHODS A retrospective chart review of operative geriatric hip fractures treated from 2015-2017 at a large tertiary care hospital was conducted. Two cohorts were compared: patients who arrived at the emergency department on a weekend, and those that arrived at the emergency department on a weekday. Primary outcome measures included mortality rate, complication rate, transfusion rate, and length of stay. Secondary outcome measures included time from emergency department arrival to surgery, time from emergency department arrival to medical optimization, and time from medical optimization to surgery.RESULTS There were no statistically significant differences in length of stay(P = 0.2734), transfusion rate(P = 0.9325), or mortality rate(P = 0.3460) between the weekend and weekday cohorts. Complication rate was higher in patients who presented ona weekend compared to patients who presented on a weekday(13.3% vs 8.3%; P = 0.044). Time from emergency department arrival to medical optimization(22.7 h vs 20.0 h; P = 0.0015), time from medical optimization to surgery(13.9 h vs 10.8 h; P = 0.0172), and time from emergency department arrival to surgery(42.7 h vs 32.5 h; P 0.0001) were all significantly longer in patients who presented to the hospital on a weekend compared to patients who presented to the hospital on a weekday.CONCLUSION This study provided insight into the "weekend effect" for geriatric hip fractures and found that day of presentation has a clinically significant impact on delivered care.     

Emergency Department Presentation After Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundRecent changes to payment models for elective total joint arthroplasty (TJA) have led to increased interest in postdischarge health care utilization. Although readmission has historically been of primary interest, emergency department (ED) presentation is increasingly a point of focus. The purpose of this review was to summarize the available literature pertaining to ED visits after total hip arthroplasty and total knee arthroplasty.MethodsPubMed, MEDLINE, and Embase were searched. Clinical studies reporting rate, reasons, and/or risk factors associated with ED presentation after TJA were included. Pooled return to ED rates were calculated using weighted means.ResultsTwenty-seven studies (n = 1,484,043) were included. After TJA, the mean 30-day and 90-day rates of ED presentation were 8.1% and 10.3%, respectively. Rates were slightly higher in total knee arthroplasty vs total hip arthroplasty patients at 30 days (11.5% vs 6.5%) and 90 days (10.8% vs 9.7%). The most common reasons for ED presentation after TJA were pain (4.6%-35%), medical concerns (5.6%-24.5%), and swelling (1.4%-17.5%). Studies analyzing the timing of ED visits found that most occurred within the first 2 weeks postdischarge. Black race and Medicaid/Medicare insurance coverage were identified as risk factors associated with ED visits.ConclusionED visits present a high burden for the health care system, as upward of 1 in 10 patients will return to the ED within 90 days of TJA. Future efforts should be made to develop cost-effective and patient-centered interventions that reduce preventable ED visits after TJA. As well, these rates should be taken into consideration when allocating resources for the care of TJA patients.     

The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures

BackgroundPatients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures.MethodsA retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit.ResultsFive hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case − 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242.ConclusionsAbnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.     

Early osteoarthritis after slipped capital femoral epiphysis

Background and purpose — Slipped capital femoral epiphysis (SCFE) results in a more or less pronounced deformity of the proximal femur, sometimes causing impingement and early osteoarthritis. We studied early osteoarthritis after SCFE and the association with deformity and self-reported hip function, pain, and quality of life.

Patients and methods — 9 women and 16 men, mean age 32 (21–50) years, 19 with unilateral and 6 with bilateral SCFE, participated. All patients had primarily been operated by pin or screw with no attempt at reposition of the slip. Hips were examined by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), which quantifies and locates cartilage degeneration. Plain radiographs were used to measure deformity as determined by the alpha angle. Outcome was assessed by Oxford hip score, Hip Groin Outcome score and EQ-5D-Visual scale.

Results — In the 19 unilateral SCFE, on the slip side dGEMRIC mean value was 533?ms (SD 112, range 357–649) versus mean 589?ms (SD 125, range 320–788) on the non-slip side, (p = 0.01). The dGEMRIC correlated negatively to the alpha angle, correlation coefficient (CC) = –0.60, (p = 0.002). Oxford hip score, pain, and EQ-5D-Visual scale correlated to dGEMRIC CC =0.43 (p = 0.03), CC =0.40 (p = 0.05), and CC =0.49 (p = 0.01) respectively.

Interpretation — After SCFE, even relatively mild residual hip deformity can be associated with cartilage degeneration. A high alpha angle was associated with worse cartilage status. The Oxford hip score identified symptoms even though our patients had not previously sought medical care after the index operation. Quality of life showed strong inverse correlation with cartilage degeneration. Objective assessment of early cartilage degeneration may be useful for treatment decisions and follow-up.     

Validität von Einweisungsdiagnosen als Prozesssteuerungskriterium

Background

Primary care physicians and specialists often refer patients to the emergency department with a specific diagnosis and request for admission. Such an external diagnosis frequently influences the initial evaluation in the emergency department. The present study aimed to evaluate the accuracy of such external diagnoses and to assess the consequences of incorrect diagnoses on length of stay and number of specialty consultations in the emergency department.

Material and methods

This was a prospective observational study over the course of 3 months in the emergency department of a tertiary care center. External admission diagnoses made by primary care physicians and specialists were categorized as “accurate”, “partially accurate” and “inaccurate”. A special analysis of the external admission diagnosed was performed for patients admitted directly to an intermediary care unit and intensive care unit or patients who were transferred directly from the emergency department to the operating room.

Results

Data for 784 patients were analyzed. Patients were on average 63.1?±?19.5 years old (minimum–maximum 18–97 years, median 68 years) and 54?% were male. After emergency department evaluation and treatment 57.8?% of external diagnoses were categorized as accurate, 23.6?% as partially accurate and 18.6?% as inaccurate. Patients with partially accurate and inaccurate diagnoses had a 3 and 6.5 times higher rate of specialty consultations in the emergency department, respectively, when compared with patients with an accurate diagnosis (number of specialty consultations n?=?0: 77.3?% vs. 54.1?% vs. 92.9?%, p?<?0.05; n?=?1: 20.0?% vs. 40.4?% vs. 6.2?%, p?<?0.05; n?=?2: 2.7?% vs. 5.5?% vs. 0.9?%, p?<?0.05, respectively. Patients with an accurate diagnosis had a shorter total length of stay than patients with a partially accurate or inaccurate diagnosis [mean?±?SD (min–max; median): 192?±?108 min (10–707 min; 181 min) vs. 246?±?126 min (27–1,026 min; 214 min) vs. 258?±?138 min (22–700 min; 232 min), p?<?0.001], respectively. Out of 85 patients admitted directly to an intermediary care unit, intensive care unit and patients who were transferred directly from the emergency department to the operating room the diagnosis was accurate, partially accurate and inaccurate in 56.5?%, 24.7?% and 18.8?%, respectively.

Conclusions

Admission diagnoses made by primary care physicians and specialists who subsequently refer patients to the emergency department are subject to certain inaccuracies. Inaccurate admission diagnoses are associated with an increased length of stay and a considerably higher rate of specialty consultation in the emergency department. Standardized operating procedures, treatment algorithms and triage systems are important to identify such incorrect diagnoses so that these patients can undergo appropriate diagnostic investigation and treatment.     

Delayed diagnosis of injuries to the diaphragm after penetrating wounds

During a 9-year period, 16 patients with a delay in diagnosis of an injury to the diaphragm after a penetrating wound were treated. The left hemidiaphragm was involved in 15 of 16 patients, and the delay in diagnosis from the time of arrival in the emergency center immediately after injury ranged from 16 hours to 14 years. In the patients in the Acute Group (delay of hours to days), three patients had diaphragmatic defects missed at the time of laparotomy, three patients had chest X-rays not immediately suggestive of diaphragmatic defects, two patients had false-negative lavages, and one patient treated elsewhere did not have a chest X-ray in the emergency room. In the patients in the Chronic Group (hernias presenting months to years after injury), four of seven patients had misreading of a recent chest X-ray or failure to have a chest X-ray performed during numerous return visits to the emergency center. Despite a variety of diagnostic maneuvers, these defects and hernias continue to be diagnosed after a delay. Careful review of early and late followup chest X-rays appears to be the easiest mechanism to avoid significant delays in diagnosis.     

Emergency department visits by demented patients with malfunctioning feeding tubes

BACKGROUND: Objective data indicate that feeding tubes in demented patients may not be efficacious and can have serious complications, but no study characterizes emergency department resource utilization for these patients. This study aimed to evaluate the incidence and resource utilization related to feeding tube malfunction in demented patients visiting the emergency department. METHODS: A retrospective chart review for all demented patients visiting the emergency department with malfunctioning feeding tubes from September 1999 to May 2001 was conducted. Demographic data, diagnoses, type of tube, length of emergency department stay, method of transportation to the emergency department, consultations, laboratory evaluation, x-ray data, and total hospital and ambulance charges were determined. RESULTS: A total of 138 emergency department visits by 33 patients occurred during this period (range of visits per patients, 1-21; mean, 4.1 +/- 4.3). Malfunctions occurred in 61 percutaneous endoscopically placed gastric tubes, 37 jejunostomy tubes, 34 gastric tubes, 4 endoscopically placed gastrostomy and jejunostomy tubes, and 2 percutaneous endoscopically placed jejunostomy tubes. This required 108 ambulance round-trips to and from the emergency department. The most frequent complication was unintentional dislodgement (n = 125). The average length of stay was 2.6 +/- 1.6 h. All the patients were seen by an emergency department physician. In addition, there were 99 surgical and 26 gastroenterology consultations about these patients. The total hospital charges, not including physician fees, were 86,234.48 dollars, and the total reimbursement (actual) from Medicare for ambulance charges was 57,664.00 dollars. During the same 21-month period, 42 feeding tubes were placed for dementia. CONCLUSIONS: The expense of emergency department visits for tube dislodgment or malfunction is a previously unreported issue involved in the tube feeding of demented patients. Extrapolation of our data yields an estimated health care charge of almost $11 million for the country per year.     

Slipped capital femoral epiphysis (SCFE) detected in a chiropractic office: a case report

Objective

To report on a case of slipped capital femoral epiphysis (SCFE), which is a somewhat rare condition but one that can present in a chiropractic clinic, particularly one with a musculoskeletal scope of practice.

Case

This is a single case report of a 16-year-old adolescent male patient who presented with an 18-month history of hip pain. Radiographs originally ordered by the patient’s family physician were read by the medical radiologist as “unremarkable.” The family physician diagnosed the patient with tendonitis.

Treatment

After reviewing the radiographs and examining the patient, the chiropractor suspected a SCFE that was confirmed with a repeat radiographic examination. The patient was referred back to his family physician with a diagnosis of SCFE and recommendation for orthopedic surgical consultation. The patient was subsequently treated successfully with surgical reduction by in situ pinning.

Conclusion

The prognosis for the SCFE patient when diagnosed early and managed appropriately is good. The consequences of a delay in the diagnosis of SCFE are an increased risk of further slippage and deformity, increased complications such as avascular necrosis and chondrolysis and increased likelihood of degenerative osteoarthritis of the involved hip later in life. The diagnosis and appropriate management of SCFE is where the chiropractor has an important role to play in the management of this condition.     

儿童急性股骨头骺滑脱症诊治分析

目的探讨儿童急性股骨头骺滑脱症的临床表现及放射影像学特征，治疗方法的选择。方法回顾性总结我院1993年1月至2001年5月收治的7例儿童急性股骨头骺滑脱的临床资料7例患儿中，男性5例，女性2例，年龄10～14岁。轻度急性股骨头骺滑脱3例，中度2例，重度2例。对于中轻度息儿，采用麻醉下股骨头骺滑脱闭合复位，对于重度患儿，闭合复位后予以克氏钢针固定。所有患儿均行髋人字形石膏固定2～3个月。拆除石膏后支具固定6～9个月．不负重下行髋关节主动功能锻炼。结果7例患儿经非手术或手术治疗后，均治愈并且髋关节功能恢复正常。结论对儿童急性股骨头骺滑脱患儿的及早诊断和合理治疗，对息儿功能恢复和并发症的预防具有特别重要的意义。     

Severity of chronic pain affects health care utilization after kidney transplantation

BACKGROUND: While the association between chronic pain and high health care utilization is a known issue in the general population, this relation has not been well studied among kidney transplantation patients. METHODS: The subjects were first-time kidney transplant recipients engrafted between 2003 and 2006 and 6 months to 5 years postoperatively. Using SF-36 Bodily Pain Scale, patients were categorized in three groups: group I, those with scores over 66.6; group II, between 66.6 and 33.3; and group III, over 33.3. The subjects' health care utilization was prospectively assessed by recording the number of hospital admission days and the frequency of home nurse visits, outpatient physician visits, and emergency department visits for any medical reason in a 6-month period. RESULTS: A stepwise increase in the frequency of patients admitted to the hospital (P=.017), and those referred to emergency departments (P=.007) was correlated with greater severity of pain in the three groups. However, the frequency of patients having outpatient physician visits (P=.30) or home nurse visits (P=.387) did not vary significantly. Similarly, with increased pain severity, an increase was observed in the number of emergency department visits (P=.005) and duration of hospital stays (P=.049), but not in the number of home nurse (P=.890) or physician visits (P=.112). CONCLUSION: The severity of pain seems to increase the amount of health care use among kidney transplant patients. To minimize associated costs, appropriate pain rehabilitation programs are suggested.     

Low revision rate after total hip arthroplasty in patients with pediatric hip diseases

Background The results of primary total hip arthroplasties (THAs) after pediatric hip diseases such as developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE), or Perthes’ disease have been reported to be inferior to the results after primary osteoarthritis of the hip (OA).

Materials and methods We compared the survival of primary THAs performed during the period 1995–2009 due to previous DDH, SCFE, Perthes’ disease, or primary OA, using merged individual-based data from the Danish, Norwegian, and Swedish arthroplasty registers, called the Nordic Arthroplasty Register Association (NARA). Cox multiple regression, with adjustment for age, sex, and type of fixation of the prosthesis was used to calculate the survival of the prostheses and the relative revision risks.

Results 370,630 primary THAs were reported to these national registers for 1995–2009. Of these, 14,403 THAs (3.9%) were operated due to pediatric hip diseases (3.1% for Denmark, 8.8% for Norway, and 1.9% for Sweden) and 288,435 THAs (77.8%) were operated due to OA. Unadjusted 10-year Kaplan-Meier survival of THAs after pediatric hip diseases (94.7% survival) was inferior to that after OA (96.6% survival). Consequently, an increased risk of revision for hips with a previous pediatric hip disease was seen (risk ratio (RR) 1.4, 95% CI: 1.3–1.5). However, after adjustment for differences in sex and age of the patients, and in fixation of the prostheses, no difference in survival was found (93.6% after pediatric hip diseases and 93.8% after OA) (RR 1.0, CI: 1.0–1.1). Nevertheless, during the first 6 postoperative months more revisions were reported for THAs secondary to pediatric hip diseases (RR 1.2, CI: 1.0–1.5), mainly due to there being more revisions for dislocations (RR 1.8, CI: 1.4–2.3). Comparison between the different diagnosis groups showed that the overall risk of revision after DDH was higher than after OA (RR 1.1, CI: 1.0–1.2), whereas the combined group Perthes’ disease/SCFE did not have a significantly different risk of revision to that of OA (RR 0.9, CI: 0.7–1.0), but had a lower risk than after DDH (RR 0.8, CI: 0.7–1.0).

Interpretation After adjustment for differences in age, sex, and type of fixation of the prosthesis, no difference in risk of revision was found for primary THAs performed due to pediatric hip diseases and those performed due to primary OA.     

Primary Malignant Peritoneal Mesothelioma in an Incarcerated Groin Hernia: Report of a Case

Malignant peritoneal mesothelioma arising from the inguinal hernia sac is rare. We report the case of a 71-year-old man examined in our emergency department for a bilateral inguinoscrotal hernia, which was recurrent in the right groin, and primary and incarcerated in the left groin. An emergency exploratory operation revealed a firm mass, 10cm in diameter, in the left inguinal hernia sac. The remaining peritoneal surface appeared macroscopically normal. Therefore, we resected the mass and performed a Rutkow hernioplasty. The patient was discharged after a short, uneventful recovery, and was referred to the oncology department for adjuvant therapy. He is now well and asymptomatic with no evidence of ascites, 26 months after his operation. A mesothelioma of the hernial sac peritoneum was the final histological diagnosis.     

Hematogenous septic arthritis of the adult hip

A retrospective review of 10 patients admitted to 4 regional hospitals between 1987 and 1997 in whom acute septic hip arthritis was diagnosed was performed to compare presentation, laboratory and radiographic findings, treatment, and outcome. Patients presented with fever, hip or groin pain, and an inability to bear weight. Most patients manifested a leukocytosis, and all patients had an elevated erythrocyte sedimentation rate. Hematogenous septic hip arthritis is rare. The consequences of a missed diagnosis are serious and include death. Clinical examination combined with appropriate laboratory and radiographic studies leads to prompt diagnosis and treatment.     

Evaluation of bone density in children with slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a condition seen during the preadolescent growth spurt, often in obese children and in children with endocrine disorders. Given that endocrine factors also play a role in bone density, a link between low bone mineral density (BMD) and SCFE was proposed. Dual energy X-ray absorptiometry (DXA) scanning of the spine and hips was performed on 12 children with SCFE and on 5 overweight children without this hip disorder. All scans were performed by the same technician using a Hologic Delphi W densitometer and were interpreted by a pediatric orthopedic surgeon certified in clinical densitometry. Z-scores were obtained using a pediatric database. Mean and standard deviation of the Z-scores were calculated, and paired t tests were used to assess differences between these subjects and the expected norm. The SCFE patients' Z-scores at each of the skeletal sites assessed (spine, femoral neck, and total hip) were greater than the mean by an average of 1 standard deviation. The control subjects' BMD was also greater than the mean. The P values were less then 0.05. These results suggest that children with SCFE do not have low BMD, but show bone density significantly greater then expected for age and sex. Although BMD is endocrinologically driven and endocrinologic abnormalities are implicated in SCFE, there appears to be no correlation between low BMD and SCFE.