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Chew MS, Donadello K, Messina A. Editorial comment to intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery: guidelines of the German society of Anaesthesiology and Intensive care medicine in collaboration with the German Association of the Scientific medical societies. J Clin Monit Comput 2024:10.1007/s10877-024-01203-9. [PMID: 39060555 DOI: 10.1007/s10877-024-01203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024]
Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center, Humanitas Hospital, Milan, Italy
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Esper G, Anil U, Konda S, Furgiuele D, Zaretsky J, Egol K. Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality. Geriatr Orthop Surg Rehabil 2022; 13:21514593221094730. [PMID: 35450301 PMCID: PMC9016569 DOI: 10.1177/21514593221094730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction The purpose of this study was to assess the hospital quality measures and
outcomes of operative hip fracture patients before and after implementation
of an anesthesiology department protocol assigning decision for a
preoperative transthoracic echocardiogram (TTE) to the hospitalist
co-managing physician. Materials and Methods Demographics, injury details, hospital quality measures, and outcomes were
reviewed for a consecutive series of patients presenting to our institution
with an operative hip fracture. In May of 2019, a new protocol assigning the
responsibility to indicate a patient for preoperative TTE was mandated to
the co-managing hospitalist at the institution. Patients were split into
pre-protocol and post-protocol cohorts. Linear regression modeling and
comparative analyses were conducted with a Bonferroni adjusted alpha as
appropriate. Results Between September 2015 and June 2021, 1002 patients presented to our
institution and were diagnosed with a hip fracture. Patients in the
post-protocol cohort were less likely to undergo a preoperative
echocardiogram, experienced a shorter time (days) to surgery, shorter length
of stay, an increase in amount of home discharges, and lower complication
risks for urinary tract infection and acute blood loss anemia as compared to
those in the pre-protocol cohort. There were no differences seen in
inpatient or 30-day mortality. Multivariable linear regression demonstrated
a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their
date of presentation (pre- or post-protocol), were both associated with
(P<0.01) a patients' time to surgery. Conclusion A standardized preoperative work flow protocol regarding which physician
evaluates and determines which patients require a preoperative TTE allows
for a streamlined perioperative course for hip fracture patients. This
allows for a shortened time to surgery and length of stay with an increase
in home discharges and was associated with a reduced risk of common index
hospitalization complications including UTI and anemia.
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Affiliation(s)
- Garrett Esper
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - David Furgiuele
- Department of Anesthesia, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Jonah Zaretsky
- Department of Medicine, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
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George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra R. Factors associated with delayed surgery in elderly hip fractures in India. Arch Osteoporos 2021; 16:7. [PMID: 33409699 DOI: 10.1007/s11657-020-00858-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation. INTRODUCTION Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India. METHODS In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models. RESULTS Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42-8.45]), fall as mode of injury (OR = 3.54 [1.61-7.80]), requiring an additional investigation (OR = 10.4 [3.4-31.81]), and requiring arthroplasty (OR = 40.57 [7.01-234.97]) were independently associated with delayed surgery. CONCLUSION Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.
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Affiliation(s)
- Jaiben George
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vijay Sharma
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India. .,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Kamran Farooque
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Samarth Mittal
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.,Department of Orthopaedic Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Liao CY, Tan TL, Lu YD, Wu CT, Lee MS, Kuo FC. Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty? J Orthop Surg Res 2020; 15:385. [PMID: 32894146 PMCID: PMC7487939 DOI: 10.1186/s13018-020-01918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty. Methods Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables. Results The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002). Discussion Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery. Level of evidence Prognostic level III
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Affiliation(s)
- Chin-Yi Liao
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Timothy L Tan
- Rothman Institute Orthopedic Research Department, Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA, 19107, USA
| | - Yu-Der Lu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Cheng-Ta Wu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Feng-Chih Kuo
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan.
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Bolat İ. Preoperative Right Ventricular Echocardiographic Parameters Predict Perioperative Cardiovascular Complications in Patients Undergoing Non-Cardiac Surgery. Heart Lung Circ 2020; 29:1146-1151. [DOI: 10.1016/j.hlc.2019.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/08/2019] [Accepted: 10/28/2019] [Indexed: 11/26/2022]
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Subramaniam K, Boisen ML, Yehushua L, Esper SA, Philips DP, Howard-Quijano K. Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience. J Cardiothorac Vasc Anesth 2020; 35:222-232. [PMID: 32888802 DOI: 10.1053/j.jvca.2020.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management. DESIGN Retrospective case series. SETTING Single institution, tertiary university hospital. PARTICIPANTS A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series. INTERVENTIONS All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team. MEASUREMENTS Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions). MAIN RESULTS Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique). CONCLUSION Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA.
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Liora Yehushua
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Dennis P Philips
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
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Brink O. Hip fracture clearance: How much optimisation is necessary? Injury 2020; 51 Suppl 2:S111-S117. [PMID: 32081388 DOI: 10.1016/j.injury.2020.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
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Affiliation(s)
- Ole Brink
- Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
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Chen X, Ma Y, Deng Z, Li Q, Liao J, Zheng Q. Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report. Clin Interv Aging 2020; 15:755-762. [PMID: 32546993 PMCID: PMC7266334 DOI: 10.2147/cia.s250620] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients. PATIENTS AND METHODS From January 2014 to January 2019, the medical records of all surgically treated elderly patients (>65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure >25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) <50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality. RESULTS There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332-8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869-17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047-1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002-185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988-51.413, p=0.040) and LVEF <50% (OR:8.803, 95% CI: 1.115-69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality. CONCLUSION Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF <50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.
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Affiliation(s)
- Xuepan Chen
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Shantou University Medical College, Shantou, People’s Republic of China
| | - Yuanchen Ma
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Zhantao Deng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qingtian Li
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - JunXing Liao
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qiujian Zheng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Correspondence: Qiujian Zheng Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, No. 106, Zhongshan Second Road, Yuexiu District, Guangzhou510000, People’s Republic of China Email
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Açan AE, Gültaç E, Kılınç CY, Özlek B, Gürsan O, Biteker M. Preoperative Mild Pericardial Effusion Is Associated With Perioperative Complications In Elderly Patients Following Hip Fracture Surgery. J INVEST SURG 2019; 33:453-458. [PMID: 31475617 DOI: 10.1080/08941939.2019.1658832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The prevalence and prognostic value of mild pericardial effusion (MPE) has not been examined in patients undergoing non-cardiac surgery. Our study aimed to assess the frequency and prognostic value of MPE in elderly patients undergoing surgery for hip fracture. Methods: This is a single center, and retrospective study including elderly patients who underwent hip fracture surgery. The medical records of all patients, aged ≥65 years with femoral neck, intertrochanteric or subtrochanteric hip fracture undergoing surgery (intramedullary hip screw, sliding compression hip screw, hemiarthroplasty, or total hip arthroplasty) from June 2014 to June 2019 were analyzed. Patients with of multiple trauma and accidents were excluded. The MPE was defined as the presence of <10 mm pericardial effusion. The primary outcomes of the study were perioperative adverse medical events and length of stay in hospital. Results: A total of 462 patients (mean age 75.2 ± 11.7 years, and 53.5% female) were enrolled. MPE was detected in 72 patients (15.6%), and 62 patients (13.4%) experienced perioperative adverse medical events. Patients with MPE were older, had higher prevalence of diabetes, coronary artery disease, and heart failure, and had longer length of stay compared to patients without MPE. Univariate analysis showed a significant association between age, diabetes, coronary artery disease, American Society of Anesthesiologists status, MPE, and perioperative adverse events. After adjustment for age, demographics, and medical history, the presence of MPE remained as significant variable associated with perioperative complications (OR: 2.543, 95% CI: 1.173-3.469, p = 0.003). Conclusion: Our study is the first to demonstrate that the presence of MPE is associated with perioperative adverse events in elderly patients undergoing hip fracture surgery.
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Affiliation(s)
- Ahmet Emrah Açan
- Department of Orthopedics and Traumatology, Muğla Sıtkı Koçman University Education and Research Hospital, Muğla, Turkey
| | - Emre Gültaç
- Department of Orthopedics and Traumatology, Muğla Sıtkı Koçman University Education and Research Hospital, Muğla, Turkey
| | - Cem Yalın Kılınç
- Department of Orthopedics and Traumatology, Muğla Sıtkı Koçman University Education and Research Hospital, Muğla, Turkey
| | - Bülent Özlek
- Department of Cardiology, Muğla Sıtkı Koçman University Education and Research Hospital, Muğla, Turkey
| | - Onur Gürsan
- Faculty of Medicine, Department of Orthopedics and Traumatology, Dokuz Eylül University, Izmir, Turkey
| | - Murat Biteker
- Department of Cardiology, Muğla Sıtkı Koçman University Education and Research Hospital, Muğla, Turkey
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