Analysis of Deaths Related to Anesthesia in the Period 1996-2004 from Closed Claims Registered by the Danish Patient Insurance Association

Background: Anesthesia is associated with complications, and some of them may be fatal. The authors investigated the circumstances under which deaths were associated with anesthesia. In Denmark, the specialty anesthesiology encompasses emergency medicine, chronic and acute pain medicine, anesthetic procedures, perioperative care medicine, and intensive care medicine.

Methods: The authors retrospectively investigated anesthesia related deaths registered by the Danish Patient Insurance Association.

Results: From 1996 to 2004, 27,971 claims were made by the Danish Patient Insurance Association covering all medical specialties, of which 1,256 files (4.5%) were related to anesthesia. In 24 cases, the patient's death was considered to result from the anesthetic procedure: 4 deaths were related to airway management, 2 to ventilation management, 4 to central venous catheter placement, 4 as a result of medication errors, 4 from infusion pump problems, and 4 after complications from regional blockades. Severe hemorrhage caused 1 death, and in 1 case the cause was uncertain.     

The effect of middle-age body weight and physical activity on the risk of early revision hip arthroplasty: a cohort study of 1,535 individuals

Background Overweight and a high level of physical activity are known risk factors for loosening of a total hip arthroplasty (THA) due to primary osteoarthritis. We wanted to investigate how these factors, together with age and sex, affect the risk of revision surgery.

Patients and methods We matched data from the Norwegian Arthroplasty Register with information on risk factors collected at a cardiovascular screening. We identified 1,535 primary THAs in the screened cohort (930 cemented implants using well-documented cement). Of the participants included, 969 were female. Mean age at screening was 49 years, at primary THA 63 years, and 69 years at the end of follow-up. We used Cox regression analysis to estimate relative risks (RRs). Event was defined as implant revision due to aseptic loosening of cup, stem or both. Follow-up was time from primary THA to event or censoring.

Results Men were at greater risk than women of loosening of the femoral stem (RR 2.0, 95% CI 1.3-3.2). Both men and women with upper-quartile body weight were at increased risk of revision due to loosening of the stem (RR 2.5 and 2.7, respectively). Men with a high level of physical activity during leisure time were at increased risk of revision due to loosening of the cup (RR 4.8, 95% CI 1.3-18). In the multivariate model with adjustment for activity, there was little association between age at primary THA and risk of revision due to loosening.

Interpretation We found that body weight and physical activity recorded long before THA affected the survival of total hip arthroplasties. Controlling for these variables weakened the association between age at primary surgery and aseptic loosening. Men had an increased risk of loosening of the femoral stem, also after controlling for lifestyle factors.     

In situ fixation of slipped capital femoral epiphysis with Steinmann pins

Background and purpose

Slipped capital femoral epiphysis (SCFE) is often treated by surgical fixation; however, no agreement exists regarding technique. We analyzed the outcome of in situ fixation with Steinmann pins.

Patients and methods

All 67 subjects operated for slipped capital femoral epiphysis at Haukeland University Hospital during the period 1990–2007 were included. All were treated by in situ fixation with 2 or 3 parallel Steinmann pins (8 mm threads at the medial end). The follow-up evaluation consisted of clinical examination and hip radiographs. Radiographic outcome was based on measurements of slip progression, growth of the femoral neck, leg length discrepancy, and signs of avascular necrosis and chondrolysis.

Results

67 subjects (41 males) were operated due to unilateral slips (n = 47) or bilateral slips (n = 20). Mean age at time of diagnosis was 13 (7.2–16) years. Mean age at follow-up was 19 (14–30) years, with a mean postoperative interval of 6.0 (2–16) years. The operated femoral neck was 9% longer at skeletal maturity than at surgery, indicating continued growth of the femoral neck. At skeletal maturity, 12 subjects had radiographic features suggestive of a previous asymptomatic slip of the contralateral hip. The total number of bilateral cases of SCFE was 32, i.e half of the children had bilateral SCFE. 3 subjects required additional surgery and mild avascular necrosis of the femoral head was seen in 1 patient. None had slip progression or chondrolysis.

Interpretation

In situ pinning of SCFE with partly threaded Steinmann pins appears to be a feasible and safe method, with few complications. The technique allows further growth of the femoral neck.Slipped capital femoral epiphysis (SCFE) is a disease of unknown etiology, but mechanical, biological and hereditary factors are likely to play a role (Barrios et al. 2005, Murray and Wilson 2008). The rationale for treatment of SCFE is to restore hip function, prevent further slip, and to reduce the risk of subsequent degenerative changes. Several surgical techniques have been recommended such as cannulated screws (Chen et al. 2009), hook-pins (Hansson 1982), specially constructed screws (Wensaas and Svenningsen 2005), and most recently surgical hip dislocation with subcapital correction osteotomy (Leunig et al. 2007). However, currently there is no evidence to support the superiority of one particular technique over another.In situ fixation is advocated by most authors (Boyer et al. 1981, Carey et al. 1987, Givon and Bowen 1999) since peroperative reduction may increase the risk of avascular necrosis (Ordeberg et al. 1983, Carney et al. 1991, Lim et al. 2007). Physiodesis to prevent further growth—thus stabilizing the physis—is recommended by some authors (Carey et al. 1987, Aronsson and Karol 1996). Slip of the contralateral hip is reported in more than half of the cases (Hägglund et al. 1988, Castro et al. 2000) and controversies exist regarding prophylactic fixation of the contralateral hip. According to Jerre et al. (1994), more than two-thirds of the contralateral slips are asymptomatic and are therefore only detected at close follow-ups including hip radiographs at short intervals. Immediate prophylactic fixation of the contralateral hip has been advocated by several authors (Hägglund et al. 1988, Schultz et al. 2002, Krauspe et al. 2004).In this paper, we present clinical and radiographic results of a novel, simple technique for in situ fixation of the femoral head with partially threaded Steinmann pins to enable further growth of the femoral neck.     

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Background and purpose

Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods

Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results

Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16–34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation

A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.A complex of ligaments on the ulnar side of the wrist supports the stability of the ulnocarpal and the distal radioulnar (DRU) joints. Included in this are the extensor carpi ulnaris (ECU) subsheath and the triangular fibrocartilage complex (TFCC), which is further subdivided into the radioulnar ligaments (RULs), the ulnotriquetral ligament (UT), and the ulnolunate (UL) ligament (Garcia-Elias 1998, Berger 2001). Injuries to the TFCC are common in dorsally angulated fractures of the distal radius fracture (Colle''s fracture) and may adversely affect functional outcome (Lindau et al. 2000). The pathomechanics of these injuries are poorly studied, however.During wrist arthroscopy, we have observed two lesions that are often present when treating TFCC lesions associated with distal radius fractures: (1) a separation of the floor of the ECU tendon sheath from the TFCC, and (2) an injury to the foveal insertion of the TFCC into the ulna. It seems probable that there must be a limit to how much the distal radius fragment can be displaced without rupture of the TFCC or fracture of the ulna.We investigated the characteristics of a TFCC injury in a cadaveric fracture model of dorsally displaced fractures. We hypothesized that (1) a TFCC lesion can be expected at a certain degree of displacement and that (2) a rupture of the foveal insertion would begin in the palmar capsule and progress dorsally, due to the dorsal displacement of the distal radius fragment.     

Is reverse hybrid hip replacement the solution?: 3,963 primary hip replacements with cemented cup and uncemented stem,from the Norwegian Arthroplasty Register

Background and purpose

Reverse hybrid hip replacement uses a cemented all-polyethylene cup and an uncemented stem. Despite increasing use of this method in Scandinavia, there has been very little documentation of results. We have therefore analyzed the results from the Norwegian Arthroplasty Register (NAR), with up to 10 years of follow-up.

Patients and methods

The NAR has been collecting data on total hip replacement (THR) since 1987. Reverse hybrid hip replacements were used mainly from 2000. We extracted data on reverse hybrid THR from this year onward until December 31, 2009, and compared the results with those from cemented implants over the same period. Specific cup/stem combinations involving 100 cases or more were selected. In addition, only combinations that were taken into use in 2005 or earlier were included. 3,963 operations in 3,630 patients were included. We used the Kaplan-Meier method and Cox regression analysis for estimation of prosthesis survival and relative risk of revision. The main endpoint was revision for any cause, but we also performed specific analyses on different reasons for revision.

Results

We found equal survival to that from cemented THR at 5 years (cemented: 97.0% (95% CI: 96.8–97.2); reverse hybrid: 96.7% (96.0–97.4)) and at 7 years (cemented: 96.0% (95.7–96.2); reverse hybrid: 95.6% (94.4–96.7)). Adjusted relative risk of revision of the reverse hybrids was 1.1 (0.9–1.4). In patients under 60 years of age, we found similar survival of the 2 groups at 5 and 7 years, with an adjusted relative risk of revision of reverse hybrids of 0.9 (0.6–1.3) compared to cemented implants.

Interpretation

With a follow-up of up to 10 years, reverse hybrid THRs performed well, and similarly to all-cemented THRs from the same time period. The reverse hybrid method might therefore be an alternative to all-cemented THR. Longer follow-up time is needed to evaluate whether reverse hybrid hip replacement has any advantages over all-cemented THR.The reverse hybrid method (also known as “inverse hybrid”) uses a cemented all-polyethylene cup in combination with an uncemented stem. This method is partly based on good clinical results of cemented cups and of some uncemented stems in the Norwegian Arthroplasty Register (NAR) (Havelin et al. 2000a,b, Hallan et al. 2007). The register has also shown that some uncemented femoral stems may have better long–term results (> 10 years) than cemented stems in patients 60 years of age or younger. Based on these findings, the NAR suggested 10 years ago that the use of cemented cups in combination with uncemented stems might be justified in young patients (Havelin et al. 2000a). In the Swedish Hip Arthroplasty Register, the performance of uncemented THR was found to be inferior to that of cemented THR (Hailer et al. 2010). The authors of that study found that cemented cups performed better than uncemented cups and that uncemented femoral stems had better survival than cemented stems, with aseptic loosening as endpoint. In the Finnish Arthroplasty Registry, Mäkelä et al. (2010) found better long-term survival regarding aseptic loosening for the best performing types of cementless stems compared to the cemented reference group, in the age group 55–74 years.McNally et al. (2000) studied survival of the Furlong HA coated femoral stem in combination with a cemented ultra-high-density polyethylene cup at 10–11 years, and found values of 99% for the stem and 95% for the cup. Alho et al. (2000) reported results with cemented Lubinus cups and uncemented Furlong stems, and they also pointed out the possibility of using the principle of reverse hybrid arthroplasty. We are not aware of any other reports on the reverse hybrid method.In a reverse hybrid THR, an uncemented stem and a modular head are most often combined with a cemented cup of another name or from another company. Combining implants that are not designed to fit each other might theoretically lead to unexpected complications such as increased wear, loosening, or dislocation. This concern was raised by the NAR already in their report from 2005 (Norwegian Arthroplasty Register 2005). As the use of reverse hybrids is increasing, we decided to evaluate the short- to medium-term results with this concept and to compare them with those from all-cemented THRs, using data from the NAR.     

Defecation disturbances after cystectomy for urinary bladder cancer

Study Type – Preference (prospective cohort) Level of Evidence 4 What’s known on the subject? and What does the study add? Functional gastrointestinal symptoms and problems are common after radical cystectomy with urinary diversion. This study adds new important epidemiological data on this group of symptoms.

OBJECTIVE

• ? To describe and compare long‐term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non‐continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions.

PATIENTS AND METHODS

• ? During their follow‐up we attempted to contact all men and women aged 30–80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals.
• ? During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study‐specific questionnaire together with free‐hand comments. The patients completed the questionnaire at home.
• ? Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval.

RESULTS

• ? The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability).
• ? A sense of decreased straining capacity was reported by 20% of the men and women with non‐continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively.

CONCLUSIONS

• ? Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability).
• ? Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool‐emptying problems, and asking about them after surgery.

     

Clinical outcome after undisplaced femoral neck fractures

Background and purpose

Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.

Methods

Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.

Results

The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.

Interpretation

Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.Each year, approximately 9,000 patients are operated for hip fractures in Norway. 19% are undisplaced femoral neck fractures (Garden 1 and 2) and 38% are displaced (Gjertsen et al. 2008). The treatment of displaced fractures has been investigated extensively, and some recent reports have shown better clinical outcome after hemiarthroplasty than after screw fixation (Rogmark et al. 2002, Frihagen et al. 2007, Gjertsen et al. 2010). Less has been published on the treatment of undisplaced fractures. Some authors advocate internal screw fixation as being the best treatment, even though a high rate of reoperations has been reported (Conn and Parker 2004, Bjorgul and Reikeras 2007, Parker et al. 2008). A recent study found poor outcome in many patients after treatment of undisplaced fractures (Rogmark et al. 2009).In Norway, there are no national guidelines for the treatment of hip fractures. The standard treatment for undisplaced fractures has been internal fixation with 2 screws or pins (94% of fractures) (Gjertsen et al. 2008). In the present study, we wanted to investigate the results after undisplaced femoral neck fractures, as reported to the Norwegian Hip Fracture Register. Risk of reoperation, pain, patient satisfaction, and quality of life were used as outcome measures. Since the undisplaced fractures were almost exclusively treated with internal fixation, patients with displaced femoral neck fractures treated with screw osteosynthesis or hemiarthroplasty were used as reference groups when analyzing the results.     

Amiodarone protects diabetics and non-diabetics undergoing coronary artery bypass grafting equally

OBJECTIVE: To evaluate amiodarone prophylaxis in diabetics and non-diabetics. Further to clarify whether the risk of developing atrial fibrillation is higher for diabetics than non-diabetic patients, and to evaluate whether the diabetic status has any influence on the length of in-hospital stay. DESIGN: Subgroup analysis within a randomized, controlled, double-blinded trial. RESULTS: At 30 days of follow-up atrial fibrillation was equally frequent among diabetics (22%) and non-diabetics (17%) (p =0.41). The length of in-hospital stay for diabetics was prolonged with 25% (9%; 45%). The prophylactic amiodarone was found equally efficient in diabetics and non-diabetics, as the relative risk ratios were 1.2 (0.4-5.4) and 2.0 (0.3-12.5), respectively. CONCLUSIONS: Diabetics and non-diabetics had the same effect of the amiodarone prophylaxis regime. Atrial fibrillation developed equally among diabetics and non-diabetics, but the length of stay was prolonged for diabetics.