Early mortality after hip fracture: is delay before surgery important?

BACKGROUND: Hip fracture is associated with high mortality among the elderly. Most patients require surgery, but the timing of the operation remains controversial. Surgery within twenty-four hours after admission has been recommended, but evidence supporting this approach is lacking. The objective of this study was to determine whether a delay in surgery for hip fractures affects postoperative mortality among elderly patients. METHODS: We conducted a prospective, observational study of 2660 patients who underwent surgical treatment of a hip fracture at one university hospital. We measured mortality rates following the surgery in relation to the delay in the surgery and the acute medical comorbidities on admission. RESULTS: The mortality following the hip fracture surgery was 9% (246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those operated on without delay had a thirty-day mortality of 8.7% and those for whom the surgery had been delayed between one and four days had a thirty-day mortality of 7.3%. This difference was not significant (p = 0.51). The thirty-day mortality for patients for whom the surgery had been delayed for more than four days was 10.7%, and this small group had significantly increased mortality at ninety days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a thirty-day mortality of 17%, which was nearly 2.5 times greater than that for patients who had been initially considered fit for surgery (hazard ratio = 2.3, 95% confidence interval = 1.6 to 3.3; p < 0.001). CONCLUSIONS: The thirty-day mortality following surgery for a hip fracture was 9%. Patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after the surgery compared with patients without comorbidities that delayed surgery. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery. However, a delay of more than four days significantly increased mortality.     

Early prediction of tibial and femoral fracture healing: Are we reliable?

IntroductionTo evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures.Materials and methodsEight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union.ResultsNine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25–0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330–0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p = 0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons’ years in clinical practice were not associated with accuracy of predictions.ConclusionsAt 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort.     

Use of a “kickstand” modification for external fixation of lower extremity fractures in children

Purpose  

To evaluate and describe the kickstand modification and its use in children with lower extremity fractures.     

Changing from analog to digital images: Does it affect the accuracy of alignment measurements of the lower extremity?

Background and purpose

Medical imaging has changed from analog films to digital media. We examined and compared the accuracy of orthopedic measurements using different media.

Methods

Before knee arthroplasty, full-length standing radiographs of 52 legs were obtained. The mechanical axis (MA), tibio-femoral angle (TFA), and femur angle (FA) were measured and analyzed twice, by 2 radiologists, using (1) true-size films, (2) short films, (3) a digital high-resolution workstation, and (4) a web-based personal computer. The agreement between the 4 media was evaluated using the Bland-Altman method (limits of agreement) using the true-size films as a reference standard.

Results

The mean differences in measurements between the traditional true-size films and the 3 other methods were small: for MA –0.20 to 0.07 degrees, and for TFA –0.02 to 0.18 degrees. Also, the limits of agreement between the traditional true-size films and the three other methods were small.

Interpretation

The agreement of the alignment measurements across the 4 different media was good. Orthopedic angles can be measured as accurately from analog films as from digital screens, regardless of film or monitor size.During the last 15 years a gradual change from traditional, analog film radiographs to digital imaging has occurred. This has implemented a change not only in the way images are obtained, but also in the way images are archived and, above all, evaluated. The image transition time in daily clinical practice has decreased (May et al. 2000). Traditional film evaluation has changed to image reading on monitor screens; this change affects not only radiologists, but also orthopedic surgeons. In addition to the change in the visual analysis of images, there has also been a change in how measurements are performed. Light boxes, rulers, and grease pencils have been exchanged for computers using graphics software.In knee surgery, it is common to assess the alignment of the whole lower extremity with a hip-to-ankle radiograph from which the mechanical axis (MA), the tibio-femoral angle (TFA), and femur angle (FA) are measured. Excellent intra- and interobserver reproducibility of analog MA measurements has been reported in several studies (Henderson and Kemp 1991, Sharma et al. 2001, Rauh et al. 2007, Gordon et al. 2009). In osteoarthritis, the tibio-femoral joint space narrowing is often unsymmetrical, leading to angular deformity of the lower extremity, more commonly of varus type. In order to be able to restore the alignment, knowledge of the preoperative malalignment is crucial. A malalignment of the knee prosthesis not only increases the likelihood of postoperative malfunction, but also affects the lifespan of the prosthesis (Sorrells et al. 2007).We investigated the accuracy of alignment measurements performed using 4 techniques: analog true-size films, films of reduced size, high-resolution workstations, and web-based personal computers (PCs). Before that, we assessed the intra- and interobserver reliability of these 4 techniques, separately for each technique.     

Femoral fractures in the polytrauma patient Early fracture fixation versus damage control orthopedics

AMEDLINEsearchwasconductedtoidentifystudiespublishedfromJanuary1999toDecember2003thataddressedthetimingoffemurfixationanddamagecontrolorthopedicsinthepolytraumapatient.Fromalistofsevenarticles,fourwerecomparativestudiesthatmadetheappropriatecomparison.StudiesStudy1BrundageSI,McGhanR,JurkovichGJ,etal(2002)Timingoffemurfracturefixation:effectonoutcomeinpatientswiththoracicandheadinjuries.JTrauma;52(2):299-307.Study2ScaleaTM,BoswellSA,ScottJD,etal(2000)Externalfixationasabridgetointr…     

Is thrombolysis of lower extremity acute arterial occlusion cost-effective?

BACKGROUND: The TOPAS (thrombolysis or peripheral artery surgery) trial randomized 544 patients with acute lower extremity ischemia to either surgery or thrombolysis. Although statistically equivalent 1-year morbidities and mortalities were demonstrated, the comparative cost-effectiveness of these two interventions has not been explored. MATERIALS AND METHODS: We constructed a Markov decision-analytic model to determine the cost-effectiveness of thrombolysis relative to surgery for a hypothetical cohort of patients with acute lower extremity arterial occlusion. Our measure of outcome was the cost-effectiveness ratio (CER), defined as the incremental lifetime cost per quality-adjusted life year gained. Estimates of 1-year outcomes were based on the TOPAS trial: mortality (lysis, 20%; surgery, 17%), amputation (lysis, 15%; surgery, 13%), the number of additional interventions required following the initial procedure (lysis, 544; surgery, 439). Procedural costs were estimated from the cost accounting system at the New York Presbyterian Hospital as well as from the literature. RESULTS: Operative intervention for acute lower extremity arterial occlusion extended life and was less costly compared to thrombolysis. The projected life expectancy for patients who underwent initial surgery was 5.04 years versus 4.75 years for initial thrombolysis. The lifetime costs were $57,429 for surgery versus $dollar;76,326 for thrombolysis. In performing sensitivity analyses, a threshold CER of $60,000 was considered what society would pay for accepted medical interventions. Thrombolysis became cost-effective if the 1-year mortality rate for lysis was lowered from 20 to 10.7%, if the amputation rate for lysis diminished from 15 to 3.9%, or if the 1-year cost of lysis could be reduced to a level below $13,000. CONCLUSIONS: Initial surgery provides the most efficient and economical utilization of resources for acute lower extremity arterial occlusion. The high cost of thrombolysis is related to the expense of the lytic agents, the need for subsequent interventions in patients treated with initial lysis, and the long-term costs of amputation in patients who fail lytic therapy.     

Are current measurements of lower extremity muscle architecture accurate?

Skeletal muscle architecture is defined as the arrangement of fibers in a muscle and functionally defines performance capacity. Architectural values are used to model muscle-joint behavior and to make surgical decisions. The two most extensively used human lower extremity data sets consist of five total specimens of unknown size, gender, and age. Therefore, it is critically important to generate a high-fidelity human lower extremity muscle architecture data set. We disassembled 27 muscles from 21 human lower extremities to characterize muscle fiber length and physiologic cross-sectional area, which define the excursion and force-generating capacities of a muscle. Based on their architectural features, the soleus, gluteus medius, and vastus lateralis are the strongest muscles, whereas the sartorius, gracilis, and semitendinosus have the largest excursion. The plantarflexors, knee extensors, and hip adductors are the strongest muscle groups acting at each joint, whereas the hip adductors and hip extensors have the largest excursion. Contrary to previous assertions, two-joint muscles do not necessarily have longer fibers than single-joint muscles as seen by the similarity of knee flexor and extensor fiber lengths. These high-resolution data will facilitate the development of more accurate musculoskeletal models and challenge existing theories of muscle design; we believe they will aid in surgical decision making. Two of the authors (SRW, RLL) have received funding from National Institutes of Health Grants HD048501 and HD050837 and the Department of Veterans Affairs. Each author certifies that his or her institution has approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.     

Selective posterior rhizotomy for lower extremity spasticity: how much and which of the posterior rootlets should be cut?

BACKGROUND: It is well known that selective posterior rhizotomy is effective for relieving spasticity associated with cerebral palsy. However, there is significant variation between surgeons in terms of how much and which of the posterior rootlets should be cut for the improvement of ambulatory function without causing adverse effects. METHODS: The study population was composed of 200 CP patients who underwent SPR more than 1 year before this study. The children were divided into 4 groups (Group A had their L1-S2 roots cut, Group B had the L2-S2 roots cut, Group C had the L2-S1 roots cut, and Group D had the L2-S1 roots and the unilateral S2 root cut). We assessed lower limb spasticity, passive range of motion, ambulatory function, and gait pattern in each group. RESULTS: Inclusion of L1 and S2 in the lesioning process of SPR was more effective at relieving spasticity in terms of hip adduction and ankle dorsiflexion respectively and improving ambulatory function (p < 0.01). Although lesioning of S2 carried a greater risk of urinary dysfunction, resection of less than 50% of S2 significantly improved ambulatory function without urinary complications (p < 0.01). Unilateral lesioning of S2 was an alternative option in selected cases with different amounts of spasticity in the ankles for the same purpose. CONCLUSIONS: We propose that L1 and S2 roots should be included in the lesioning process of SPR for effective improvement of gross motor function, but that resection of these roots should be less than 50% to prevent complications.     

FRAX? probabilities and risk of major osteoporotic fracture in France

Summary

The incidence of hip fracture, death and the estimated incidence of major osteoporotic fracture in France were used to determine the lifetime and 10-year probability of fracture and incorporated into a probability model (FRAX?) calibrated to the French population.

Introduction

Fracture probabilities in the French population have not been determined. Our aim was to determine the incidence of hip fracture in France and the estimated 10-year probabilities of hip and major osteoporotic fractures.

Methods

The study population included adults over 50?years living in France in 2004. Incident hip fracture cases were identified from the French PMSI database. Incidence of the other major osteoporotic fractures was imputed from the relationship between hip fracture incidence and other major fracture in Sweden. These data were used to calculate population-based fracture probabilities according to age and BMD using cutoff values for femoral neck T-scores from the NHANES III data in Caucasian women. The probability model (FRAX?) calibrated to the French population was used to compute individual fracture probabilities according to specific clinical risk factors.

Results

We identified 15,434 men and 51,469 women with an incident hip fracture. The remaining lifetime probability of hip fracture at 50?years was approximately 10 and 30% respectively. With a femoral neck T-score of ?2 SD, one in two women and one in five men would sustain a major osteoporotic fracture in their lifetime. The 10-year probability of other major osteoporotic fractures increased with declining T-score and increasing age. Low body mass index and other clinical risk factors had an independent effect on fracture probability whether or not BMD was included in the FRAX? model.

Conclusion

This analysis provides detailed estimation on the risk of fracture in the French population and may help to define therapeutic guidelines.     

Is routine preoperative aortoiliac arteriography necessary in the treatment of lower extremity ischemia?

Purpose: To determine whether preoperative aortoiliac arteriography can be replaced with noninvasive evaluation in the management of some patients with chronic lower extremity ischemia. Methods: Preoperative evaluation was performed on 184 ischemic limbs (119 patients) over 19 months by means of aortoiliac arteriography with runoff and noninvasive studies, which included common femoral artery duplex scanning, waveform and acceleration time (normal <140 msec), and aortoiliac duplex scanning. An algorithm was proposed for combining indirect (common femoral artery evaluation) and direct (aortoiliac evaluation) noninvasive studies to decrease the need for aortoiliac arteriography when possible. Results: Aortoiliac occlusive disease (≥50% stenosis to occlusion) was present at arteriography in 48 limbs (30%), and there was no inflow disease in 114 (70%). Aortoiliac lesions were identified by means of noninvasive studies. The accuracies of femoral waveform, acceleration time, and aortoiliac duplex studies were 85%, 89% and 87%. The negative predictive values were 92%, 94% and 100%. The acceleration time results were not affected by runoff status but were significantly different for various categories of stenosis (p < 0.05). The algorithm was applied to the data obtained. When acceleration time and waveform were normal, 84 of 86 patients (98%) had no stenosis at arteriography. When aortoiliac duplex findings were normal, the arteriographic findings were normal in all examinations. Conclusion: A combination of indirect and direct noninvasive studies can be used reliably to rule out clinically significant inflow occlusive disease and allows selective use of aortoiliac arteriography in patients with lower extremity ischemia. (J Vasc Surg 1998;28:28-36.)     

Severity of vertebral fracture and risk of hip fracture: a nested case�Ccontrol study

Summary  

Severe vertebral fractures strongly predicted subsequent hip fracture in this population-based study. Such high-risk patients should be provided with clinical evaluation and care for osteoporosis.     

Does the sequence and timing of total shoulder arthroplasty relative to lower extremity arthroplasty influence postoperative complications?

BackgroundAs the number of total knee, hip, and shoulder arthroplasties increases, so do the number of patients requiring multiple arthroplasties in different joints. Evidence-based guidance on the sequence and timing of hip and knee arthroplasty (TJA) in total shoulder arthroplasty (TSA) patients is lacking. The objectives of the present study were to examine the relationship between the sequence and timing of these lower extremity arthroplasties on surgical and medical complications following TSA.MethodsPatients from the 100% Medicare dataset who underwent lower extremity Total Joint Arthroplasty (TJA) and TSA between 2005 and 2014 were identified. Patients were stratified into 6 groups: (1) patients who underwent TSA less than 3 months after TJA, (2) patients who underwent TSA between 3 months and 1 year after TJA, (3) patients who underwent TSA greater than 1 year after TJA, (4) patients who underwent TSA less than 3 months prior to TJA, (5) patients who underwent TSA between 3 months and 1 year prior to TJA, and (6) patients who underwent TSA greater than 1 year prior to TJA. Revision rate, indication for revision surgery, and medical complications of all groups were compared using a regression analysis.ResultsPatients who underwent TSA within 3 months prior to lower extremity TJA had a significantly higher incidence of revision shoulder surgery and unplanned emergency department visits within 90 days compared to all other groups (P < .05). These patients had higher rates of implant wear, periprosthetic lysis, and mechanical complications as the indication for revision compared to all other patients who also underwent revision surgery (P < .05).ConclusionTSA should be performed greater than 3 months before lower extremity TJA or at any point following lower extremity TJA to avoid the increased risk of revision surgery due to implant wear or lysis and increased rates of emergency room presentation.Level of evidenceLevel III