[Secondary prevention in osteoporotic fractures. The GIOS project]

BACKGROUND AND OBJECTIVE

The aim of this report is to describe and evaluate the results of a secondary prevention program in osteoporotic fractures in 70 Spanish hospitals. This project was started to improve the treatment of these fractures, with the inhospital implementation of software collecting epidemiological data on patients with osteoporotic fractures.

PATIENTS AND METHODS

A prospective case study was conducted between March 2003 and March 2006 involving a consecutive sample of 24,534 patients with established fragility fracture seen in 70 hospitals. The study exclusion criterion was secondary osteoporotic fracture. The project consists of implementing software in hospitals, designed to collect such epidemiological data among these patients. Based on this information and on the published scientific evidence, the software automatically generates drug therapy recommendations and non pharmacologic measures of prevention to be included in the discharge report.

RESULTS

The number of patients with osteoporotic fractures included in the program totalled 24,534 subjects. Of these patients, only 22.7% were receiving treatment for osteoporosis. Implementation of the program made it possible to discharge 19,033 patients (77.6%) with prescribed treatment, but in only 15,153 patients (61.8%) the treatment was correct.

CONCLUSIONS

The GIOS project has proved effective in increasing the identification of fragility fractures and improve the percentage of secondary prevention measures, both pharmacological and non pharmacological, for patients with these fractures.

Long-term remodeling in proximal femur around a hydroxyapatite-coated anatomic stem: ten years densitometric follow-up

Bone remodeling after a hip arthroplasty has been quantified with dual energy x-ray absorptiometry, usually for short-term follow-up. We used this technique to determine the long-term remodeling produced by a hydroxyapatite-coated, anatomic stem. Eighty patients with unilateral hip osteoarthritis were included in the study. The contralateral, healthy hip was taken as control. Bilateral dual energy x-ray absorptiometry scans were done before the surgery, at 15 days, and 1 and 10 years postoperatively. There was a decrease of bone mineral density in zones 1 and 7, which ranged from 12.2% to 27.3% at the end of the first year. There were no changes in zones 1 to 6 from the 1st to the 10th year, but there was a late decrease, up to 42.9%, in zone 7. The changes of bone mineral density promoted by this stem occurred in the first postoperative year. Late loss was seen only in area 7.

Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data

INTRODUCTION

An important percentage of patients affected by hip fracture require the administration of allogenic blood transfusion (ABT) to avoid the risks of perioperative acute anaemia. However, concerns about ABT risks have led to the search for alternatives, especially in elective orthopaedic surgery.

MATERIALS AND METHODS

We have prospectively investigated the effect of preoperative intravenous 200-300 mg (group 2; n=20) iron sucrose on ABT requirements and postoperative morbid-mortality in patients undergoing surgery for displaced subcapital hip fracture (DSHF) repair. A previous series of 57 DSHF patients served as the control group (group 1). All patients were older than 65 years, were operated on the 3rd day after admission to the hospital, by the same medical team, and using the same implant. Age, gender, ASA classification, surgical procedure, perioperative haemoglobin, requirements for ABT, postoperative infection, length of hospital stay (LOS) and 30-day mortality rate were examined.

RESULTS

No adverse reactions to the iron administration were observed. The iron group had a lower transfusion rate (15% vs 36.8%), lower transfusion index (0.26 vs 0.77 units per patient), lower 30d mortality rate (0 vs 19.3%), shorter LOS (11.9 vs 14.1 days), as well as a trend to a lower postoperative infection rate (15% vs 33%).

CONCLUSION

Preoperative parenteral iron administration could be a safe and effective way to reduce the ABT requirements in DSHF patients. This reduction in the ABT requirements is accompanied by a reduction in the morbid-mortality rate and LOS. A large, randomised, controlled trial to confirm these results is warranted.

Rotator interval closure after arthroscopic capsulolabral repair: a technical variation

Rotator interval tear is one of the lesions identified in patients with glenohumeral instability. We present our technique for arthroscopic interval capsule repair. After having performed Bankart reconstruction, we pull the anterosuperior cannula back some millimeters and introduce a Penetrator suture retriever forceps (Arthrex, Naples, FL) through the upper interval capsule into the joint. Then we also remove some millimeters of the anterior cannula and introduce a suture passer (Spectrum; Linvatec, Largo, FL) loaded with a monofilament suture through the lower interval capsule. The suture is pushed into the joint and, using the Penetrator suture retriever forceps, we retrieve it out of the joint. This suture is replaced if desired by a permanent braided suture. Next, a suture passer (Arthrex) advances the end of the suture from the anterosuperior portal into the joint. The suture is retrieved out of the joint from the anterior cannula with a crochet hook. We tie the suture down the anterior cannula to close the anterior capsule. Because we use cannulas, we can use a sliding knot. The degree of tightening can be observed directly under arthroscopic view but the knot is outside of the capsule. We believe that this method is easy, effective, and reproducible.

Perioperative stimulation of erythropoiesis with intravenous iron and erythropoietin reduces transfusion requirements in patients with hip fracture. A prospective observational study

BACKGROUND AND OBJECTIVES

Patients undergoing surgery for hip fracture (HF) often receive perioperative allogeneic blood transfusions (ABT) to avoid anaemia. However, concerns about the adverse effects of ABT have prompted the review of transfusion practice and the search for a safer treatment of perioperative anaemia.

MATERIALS AND METHODS

We prospectively investigated the effect of a blood-saving protocol of perioperative iron sucrose (3 x 200 mg/48 h, intravenously) plus erythropoietin (1 x 40,000 IU, subcutaneously) if admission haemoglobin level < 130 g/l, on transfusion requirements and postoperative morbid-mortality in patients with HF (group 2; n= 83). A parallel series of 41 HF patients admitted to another surgical unit within the same hospital served as the control group (group 1). Perioperative blood samples were taken for haematimetric, iron metabolism and inflammatory parameter determination.

RESULTS

This blood-saving protocol reduced the number of transfused patients (P < 0.001), the number of transfused units (P < 0.0001), increased the reticulocyte count and improved iron metabolism. In addition, the blood-saving protocol also reduced the rate of postoperative infections (P = 0.016), but not the 30-day mortality rate or the mean length of hospital stay.

CONCLUSIONS

The blood-saving protocol implemented seems to reduce ABT requirements in patients with HF, and is associated with a lower postoperative morbidity. The possible mechanisms involved in these effects are discussed.

Marchetti nailing of closed fresh humeral shaft fractures

INTRODUCTION

The purpose of this study was to analyse the results of Marchetti nailing.

METHOD

Between 1995 and 2003, 143 patients with closed fresh humeral shaft fractures were treated with the Marchetti-Vicenzi nail. The fractures were classified according to the AO classification: 37 A1, 24 A2, 25 A3, 22 B1, 15 B2, 7 B3, 7 C1, 4 C2 and 2 C3.

RESULTS

Fracture healing was obtained in 136 cases. The mean healing time was 11 weeks. There were seven non-unions. The range of motion of the shoulder was excellent in 95 patients (66.4%), moderate in 43 (30%) and poor in five (4.2%). The elbow had an excellent range of motion in 89 patients (62.2%), moderate in 48 (33.5%) and poor in six (4.2%). The functional result was excellent in 56 patients (39.1%), good in 62 (43.3%), fair in 18 (12.6%) and poor in seven (4.9%).

CONCLUSION

Marchetti-Vicenzi nailing appears to be a good method for the treatment of humeral shaft fractures. It is technically easy and its results are satisfactory.

[Preoperative blood test results and type of fracture as transfusional risk factors in patients older than 65 years with trochanteric hip fracture]

OBJECTIVE

To determine the effect of risk factors for allogenic blood transfusion in surgery for trochanteric hip fractures.

PATIENTS AND METHODS

A retrospective study of all the trochanteric hip fracture patients older than 65 years who underwent surgery to repair trochanteric hip fracture related to osteoporosis in 2000 and 2001 in a regional hospital. Data recorded were age; gender; type of fracture (international AO classification); level of anesthetic risk (ASA classification); hemoglobin concentration and hematocrit upon admission, on the day of surgery and 2 days later; time elapsing between admission and surgery; blood transfusion and blood product use.

RESULTS

One hundred two patients (29 men and 73 women) with trochanteric hip fractures were studied. Mean (+/- SD) patient age was 82.9 +/- 8.8 years (range, 65-99 years). Upon admission, mean hemoglobin was 123 +/- 18.1 g/L (range, 56-154 g/L), hematocrit was 37% +/- 5% (range, 10%-40%). Time elapsing until surgery was 3.5 +/- 1.6 days (range, 0-8 days). Admission hemoglobin concentration was lower in patients who required transfusion (116 g/L) than in patients who did not (133 g/L) (P < 0.001). Logistical regression analysis identified only AO classification of fracture type (P < 0.05) and admission hemoglobin concentration (P < 0.001) as independent risk factors for transfusion.

CONCLUSIONS

The hemoglobin level at admission and the trochanteric fracture type bear a relation to transfusion needs. These results suggest that in elderly patients we should improve hemoglobin levels and initiate blood salvage measures in order to reduce the need for allogenic blood transfusion, with its inherent risks.

Patients with pertrochanteric hip fracture may benefit from preoperative intravenous iron therapy: a pilot study

BACKGROUND

Patients undergoing pertrochanteric hip fracture (PHF) repair surgery often receive perioperative allogeneic blood transfusions (ABTs) to avoid the deleterious effects of anemia. Nevertheless, concerns about adverse effects of ABTs have prompted the review of transfusion practice and the search for a safer treatment of perioperative anemia.

MATERIAL AND METHODS

The effect of preoperative 200 to 300 mg of intravenous (IV; Group 2; n = 55) iron sucrose administration on transfusion requirements and postoperative morbidity-mortality in patients with PHF has been prospectively investigated. A previous series of 102 PHF patients served as the control group (Group 1). All patients were older than 65 years and were operated on at the third day after admission to the hospital, by the same medical team and with the same implant.

RESULTS

Iron sucrose was well tolerated and reduced the transfusion rate in patients with admission hemoglobin levels of greater than 120 g per L (p < 0.05) who also received fewer units of red blood cells (p < 0.05). In addition, iron sucrose reduced postoperative infection rate (p < 0.05), but not 30-day mortality rate or mean length of hospital stay.

CONCLUSION

The administration of IV iron sucrose seems to reduce ABT requirements in patients with PHF and is associated to lower postoperative morbidity. The possible mechanisms involved in these effects are discussed.

Treatment of humeral shaft nonunions: nailing versus plating

INTRODUCTION

The aim of this study was to compare plating and nailing for treating nonunions of the upper two-thirds of the humerus.

MATERIALS AND METHODS

Fifty nonunions of the upper two-thirds of the humerus were treated by two different methods: 24 of them by unreamed locked nailing and bone graft (group A), and the other 26 by plate fixation and bone grafting (group B).

RESULTS

All fractures healed in both groups. In group A, the time required for healing was 4.2 months (range 4-6 months), whereas in group B it was 4.7 months (range 4-6 months). This difference was statistically significant ( p<0.05). Functional results and the range of motion of the shoulder and elbow were similar with both techniques. In group B there were 3 cases of transient, iatrogenic, radial nerve palsy.

CONCLUSIONS

We feel that both plate fixation and the unreamed humeral locked nail are good alternatives for the treatment of humeral shaft nonunions, although nailing achieves union earlier and has fewer complications.

The incidence of distal forearm fractures in Zaragoza (Spain)

We present the results of a retrospective study of the epidemiology of distal forearm fractures in patients over 15 years of age in Zaragoza (Spain) during 1998-1999. We analysed a total of 2506 fractures of the distal forearm. Fractures were classified according to age, sex, Frykman classification and mechanism of injury. Fractures were Frykman type III in 23.5% of cases, Frykman II in 17.9%, Frykman IV in 14.5% and Frykman I in 12.8%. The rest of fractures were distributed homogeneously between the remaining fracture types. The mechanisms of injury was low energy in 78.2% of cases and high in 21.8%. Analysis of the age distribution showed an increase in the incidence of this type of fracture over 50 years of age, with a peak between 60 and 69 years as a result of accidental falls. We found an increased incidence in males below 49 years of age, as a result of traffic accidents, and a predominance of females over 50 years of age due to osteoporosis and an increased number of falls.

Extraspinal bone hydatidosis

BACKGROUND

Bone hydatidosis caused by the tapeworm larva, Echinococcus granulosis, is rare. Extraspinal locations are even rarer. We report our experience with the treatment of twenty-six patients with extraspinal osseous hydatidosis.

METHODS

Between 1972 and 1998, we treated twenty-six patients with extraspinal hydatidosis. There were sixteen men and ten women, with a mean age of 51.5 years. The mean duration of follow-up was 12.8 years. The infected area was the ilium in four patients, the ilium and sacral ala in two, the ilium and hip in eight, the femoral head and the acetabular roof in five, the femoral shaft in one, the distal part of the femur in one, the femoral head in one, the scapula in two, and the ribs in two. All patients were treated with curettage or wide resection. Chemotherapy was used in all but five patients.

RESULTS

Nineteen patients (73%) were free of disease at the time of the last follow-up. Repeated curettage or wide resection was necessary in nine of these patients; it was required in three of the nine because of surgical wound infection and in six because of recurrence. Of the seven patients who were not free of disease at the time of the last follow-up, six had persistent chronic productive sinuses and one had a chronic wound infection. The cases involving both the ilium and the hip were the most difficult to treat. Radical surgery is difficult in this location, and numerous surgical procedures were always required.

CONCLUSIONS

The results of treatment of osseous hydatidosis are satisfactory only in locations where complete and wide excision is possible. In the pelvis and hip, where radical surgery is almost impossible, the results are disappointing.

Good results with unreamed nail and bone grafting for humeral nonunion: a retrospective study of 21 patients

21 patients with humeral shaft nonunions were treated by retrograde nailing with the unreamed humeral nail. In all cases, we reamed the fracture site and performed a bone graft. Union of the fracture occurred in every case. The mean healing time was 4.2 (4-6) months. The range of motion of the shoulder and elbow was excellent in 14 patients, that of the shoulder moderate in 6 and poor in 1, and that of the elbow moderate in 7. The functional results were excellent in 13 patients, good in 5 and fair in 3. Given the good functional results in this series, retr grade locked nailing and bone grafting appears to be a good method for treating humeral shaft nonunions.

Marchetti nailing with decortication and bone graft in non-unions of the two upper thirds of the humerus

METHOD

Twelve patients with humeral shaft non-unions were treated using a Marchetti-Vicenzi nailing. The fractures site was decorticated and bone graft added.

RESULTS

Fracture healing was obtained in all cases. The mean healing time was 4.7 months. The range of motion of the shoulder was excellent in nine patients, moderate in two and poor in one. The elbow had an excellent range of motion in ten patients, moderate in one and poor in one. The functional result was excellent in nine patients, good in two, and fair in one.

CONCLUSION

Marchetti-Vicenzi nailing with bone grafting appears to be a good method for the treatment of humeral shaft non-unions. It is technically easy and its results are satisfactory.

Hydatidosis of the pelvis and hip

We report eight cases of osseous hydatidosis involving the pelvis and hip. All patients were treated by curettage and albendazole therapy. In three cases, in which only the ilium was involved, the outcome was satisfactory. The remaining patients required several debridement procedures in combination with chemotherapy and two developed chronic lesions. We conclude that treatment for this condition is difficult and when the osseous involvement is extensive the prognosis is poor.

Changes in the morphology of hip fractures within a 10-year period

The objective of this study was to find out whether the morphology of various types of hip fractures and the mean ages of the patients had changed in a recent 10-year period. All patients aged 65 years or more with acute hip fracture admitted to Miguel Servet University Hospital in 1989-1990 (n = 457) and in 1999-2000 (n = 518) were studied. The results showed a significant increase in the incidence of displaced cervical fractures (P < 0.001) and a decrease in the incidence of nondisplaced cervical fractures (P < 0.001) in women. The incidence of different types of trochanteric fractures did not vary. No change was observed in the mean age of patients with cervical fractures, but the mean age of women with A12 trochanteric fractures was significantly higher in 1999-2000 than in 1989-1990 (P < 0.05).

Asymmetrical bilateral traumatic hip dislocation with ipsilateral acetabular fracture

We report a case of simultaneous asymmetrical bilateral traumatic hip dislocation, with one hip dislocated anteriorly and the other posteriorly, with ipsilateral acetabular fracture, suffered in a traffic accident by a 36-year-old man. Closed reduction of both hips was performed, followed by delayed internal fixation of the acetabular fracture.

Asymmetrical bilateral traumatic hip dislocation with ipsilateral acetabular fracture

We report a case of simultaneous asymmetrical bilateral traumatic hip dislocation, with one hip dislocated anteriorly and the other posteriorly, with ipsilateral acetabular fracture, suffered in a traffic accident by a 36-year-old man. Closed reduction of both hips was performed, followed by delayed internal fixation of the acetabular fracture.