Effectiveness of a multidisciplinary team approach to hip fracture management

The purpose of the current study was to evaluate the effectiveness of a multidisciplinary Hip Fracture Service in the treatment of hip fractures in elderly patients. Baseline information and hospital outcomes were compared for 510 patients over the age of 65 with hip fracture treated before and after the institution of the Hip Fracture Service. Data included basic demographic data, admission laboratory results, surgical information, number of comorbidities, mortality, medical complications, discharge information, time to surgery, and length of stay in hospital. The demographics of the two groups of patients were similar. Patients treated as part of the Hip Fracture Service had fewer medical complications (36% vs. 51%), more often had surgery within 24 hours (63% vs. 35%), and had shorter hospital stays (mean, 5.7 days vs. 8.1 days) than patients treated before the Hip Fracture Service. These findings provide the rationale for a prospective, randomized trial of the service.

Brief postoperative delirium in hip fracture patients affects functional outcome at three months

It is unclear how brief postoperative delirium (DEL) affects functional outcomes. In this study, we sought to determine if patients with brief postoperative DEL (<6-wk duration) have different living situations when compared with non-DEL patients after hip fracture repair. In a prospective study, patients admitted to the geriatric hip fracture service were assessed every postoperative day for the presence of DEL using the confusion assessment method (CAM) score. Patients were reassessed at 6 wk and 3 mo postoperatively for CAM score, current living situation, and activities of daily living. Group comparisons were tested after dividing patients into two groups: DEL (DEL; [+] CAM at any time during the postoperative period while in the hospital); no-DEL (no DEL; [-] CAM throughout the postoperative period while in the hospital). The study included 92 patients of whom 26 (28%) were CAM (+) after surgery. At 6 wk follow-up, n = 81; at 3 mo follow-up, n = 76. Eight patients died during the study. At 6 wk and 3 mo, a larger percentage of DEL patients were not living with a family member (27% versus 8% patients not living with a family member at 3 mo follow-up in DEL and no-DEL, respectively). There was no difference in activities of daily living by 3 mo. We conclude that brief postoperative DEL lasting <6 wk is a determining factor for poor long-term functional outcome after hip fracture repair, because it significantly impacts the ability to live independently.

IMPLICATIONS

Brief postoperative delirium lasting <6 wk is a determining factor for poor long-term functional outcome after hip fracture repair, because it significantly impacts the ability to live independently.

In-hospital outcome and resource use in hip arthroplasty: influence of body mass

To determine the influence of body mass index (BMI) on perioperative morbidity, functional recovery, and hospital use, the records of 207 patients who underwent primary total hip arthroplasty were reviewed and patients were grouped according to BMI. Transfusion requirements, operative complications, functional recovery, and assistance needed for transfers from supine to sit, sit to stand, and bed to chair positions were analyzed at the first physical therapy. Compared with others, morbidly obese patients (BMI > or = 40 kg/m2) had significantly longer mean operative time and higher mean intraoperative blood loss (P<.05), a trend toward more complications, but no significant difference in functional recovery and hospital use.

A comparison of digital cameras: features essential for the orthopaedic surgeon

To make recommendations for the selection of digital imaging equipment and its use in the typical orthopaedic surgery practice, we investigated four digital cameras with maximal resolution ranging from 1.3-3.34 megapixels. We took images of a plain radiograph, a magnetic resonance image, a hand model, and a minifragment plate with all four digital cameras and a 35-mm film camera. Several variables were evaluated to determine their effect on image quality, including adjusting maximal camera resolution, using a flash, using a camera stand, and using a macromode. Images were graded on a 3-point scale on the computer desktop and as 5 x 7 inch prints by two blinded observers. A maximal camera resolution of 2.1 megapixels was required to make photograph-quality 5 x 7 inch prints of all subjects imaged. No difference in print quality was seen between images taken in the highest quality JPEG format and the uncompressed TIFF format. A macromode with closest focal length less than 5 inches was needed for imaging small subjects. The 1.3-megapixel camera was comparable with the higher resolution cameras for imaging radiographic studies and when viewing color images on the computer desktop.

Evaluating the quality of Internet-derived information on plantar fasciitis

Patients seeking medical advice increasingly turn to the World Wide Web. To test the hypothesis that Internet-provided medical information often is inaccurate and biased, we selected a common musculoskeletal condition. Three common Internet search engines were used to search "plantar fasciitis" and "plantar fascitis." Combining the first 50 web addresses from each search engine for both phrases and eliminating duplicate sites resulted in a database of 152 websites. Each website then was analyzed for authorship, sponsoring agency, and presence of financial incentive. The informational value score of each site then was graded using a 10-point scale evaluating the following parameters: basic definition of plantar fasciitis, causes and risk factors, clinical symptoms, diagnostic tests, differential diagnosis, conservative and surgical treatment options, and complications. The overall mean information value score for all 152 sites was 3.8 points; 36% of the sites showed financial bias. The highest mean scores among all authorship and sponsorship categories belonged to orthopaedic surgeons and academic institutions with mean scores of 7.1 and 6.1 points, respectively. Sites without obvious financial bias had significantly higher information value scores than sites with financial interests. Healthcare professionals should consider these findings when advising patients.

Searching the medical literature

Medical literature searches have become more complex because of the increasing amount of published material and the multiple available databases indexing those publications. Although newly graduated physicians may have received some training in literature searching as part of a medical school curriculum, most clinicians have received no formal training in this skill. In today's world of evidence-based medicine, access to published data is crucial, and the importance of a systematic approach to searching cannot be overemphasized. A brief review of searching techniques can greatly increase productivity while using the MEDLINE, Excerpta Medica, Science Citation Index, and other databases. Similarly, knowing the options available for remote access to databases and electronic delivery of articles can expedite the task of accessing publications.

Treatment of osteoarthritic cartilage lesions with osteochondral autograft transplantation

Twenty-two osteochondral autograft transplantations were performed on two types of knees: those with isolated (group 1) and multiple (group 2) degenerative cartilage lesions. At minimum 24-month follow-up, group 1 had significantly better pain relief and function than group 2 based on the Western Ontario and McMaster Universities Osteoarthritis Index and pain scores (10-point visual analog scale). Osteochondral autograft transplantation may be effective in treating knees with isolated degenerative cartilage lesions but appears contraindicated in those with multiple lesions.

Postoperative fever after total knee arthroplasty: the role of cytokines

Febrile temperatures commonly are seen after total knee arthroplasty, but their source and importance are unclear. The goal of the current study was to determine whether such fevers are part of the normal physiologic response to surgery mediated by inflammatory cytokines. In 20 patients who had total knee arthroplasty, serum and wound drain fluid samples were collected preoperatively and at 1, 6, 24, and 48 hours postoperatively; oral temperatures were measured postoperatively every 4 hours for 3 days. Concentrations of interleukin 1beta, interleukin 6, and tumor necrosis factor alpha in the samples were measured via enzyme-linked immunosorbent assays and compared in patients who did and did not have fevers develop (>or=38.5 degrees C). Gender, age, operative time, amount of blood loss or drain output, anesthesia type, drop in hematocrit, and transfusion administration were not associated with fever. Significant increases were seen postoperatively in drain fluid concentrations of interleukin 1beta and interleukin 6 and in serum concentrations of interleukin 6. Patients who were febrile had significantly higher drain and serum interleukin 6 concentrations than patients who were afebrile. These findings suggest that fevers seen after total knee arthroplasty are at least partly the result of surgical site inflammation and subsequent local and systemic release of the endogenous pyrogen interleukin 6.

Ex vivo magnetic resonance microscopy of an osteochondral transfer

A 49-year-old woman with right knee pain and a chondral defect on the medial femoral condyle underwent an osteochondral transfer. The patient initially had pain relief, but then sustained a twisting injury and had progressive chondromalacia and pain on the affected side. She subsequently underwent a total knee replacement, and the tissue from the osteochondral transfer (OATS) site was harvested for analysis. In vitro MR microimaging of the excised joint segment revealed undamaged, full-thickness cartilage on the OATS plug, intact cartilage on the posterior condyle, and severely thinned and damaged cartilage on the anterior condyle. Alcian blue-stained sections revealed that proteoglycans were present throughout the OATS core but were nearly absent in the native cartilage. Quantitative T(1) data acquired after equilibration with Gd-DTPA indicated a distribution of matrix fixed charge in the OATS plug and anterior tissue that agreed well with histology and literature observations, while the posterior native cartilage appeared to have fixed charge similar to that of the OATS tissue. Histology revealed poor graft integration between OATS and native cartilage, with a distinct layer of fibrous tissue at the posterior interface. MRI images, by comparison, showed a hypointense feature at the posterior interface but uniform intensity across the anterior interface. Quantitative T(2), magnetization transfer and T(1) data acquired with and without gadolinium contrast showed dependences on depth, location, and pathology that were consistent with measurements reported in the literature for articular cartilage.

The economic impact of medical complications in geriatric patients with hip fracture

The records of 510 elderly patients with hip fractures admitted to our institution between January 1995 and December 2000 were retrospectively reviewed to determine the incidence and type of developed medical complications and their economic implications. Of those 510 patients, 217 (43%) developed at least 1 medical complication, most frequently electrolyte imbalance (11%), urinary tract infection (10%), respiratory failure (10%), and delirium (9%). Patients who developed medical complications had significantly longer mean hospital stays (10 days) and higher mean hospital costs ($16,203) than patients without such complications (5 days and $10,284, respectively) (P<.001).

Mini-incision total hip arthroplasty: a comparative assessment of perioperative outcomes

Compared with patients with total hip arthroplasty (THA) via a direct lateral approach, patients treated with THA via a mini-incision approach had significantly earlier ambulation, less transfer assistance, and more favorable discharge dispositions; they also had decreased transfusion requirements and better functional recovery with early physical therapy. This procedure achieved accurate and reproducible implantation, regardless of patient habitus.

Preoperative factors associated with postoperative change in confusion assessment method score in hip fracture patients

Postoperative delirium is a major problem in elderly patients undergoing surgical repair of hip fracture. It is imperative to identify potentially treatable preoperative factors associated with the onset of postoperative delirium to optimize outcome. We sought to determine what preoperative variables are associated with postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. In a prospective, IRB-approved study, patients admitted to the geriatric hip fracture service were examined daily in the hospital for the occurrence of postoperative delirium. All patients with a preoperative diagnosis of dementia or delirium were eliminated. A positive confusion assessment method score ([+]CAM) was used to determine the presence of postoperative delirium during the acute hospital stay. To determine the association between preoperative variables (demographics, laboratory values, and comorbidities) and postoperative (+)CAM scores, chi(2) and logistic regression analysis were performed with calculation for the odds ratios (OR). One-hundred-sixty-eight patients (72% women) were included in the analysis. Twenty-eight percent (n = 47) of patients had a (+)CAM score. Three variables were significant predictors of a (+)CAM score: (a) normal white blood cell count (OR, 2.2), (b) abnormal serum sodium (OR, 2.4); and (c) ASA physical status >II (OR, 11.3). The results suggest that preoperative medical conditions (abnormal serum sodium and ASA physical status >II) and an inability to mount a stress response (normal white blood cell count) may influence the patient's postoperative mental status. In particular, two of the risk factors we identified may be amenable to therapy and are abnormal serum sodium and lack of an increase in white blood cell count during the stress of trauma and surgery.

IMPLICATIONS

This prospective study investigated preoperative variables that are predictive of postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. The results suggest that the patient's preoperative medical condition and inability to mount a stress response influence postoperative delirium.

Pigmented villonodular synovitis: keys to early diagnosis

Pigmented villonodular synovitis is a synovial proliferative disorder that remains a diagnostic difficulty. Many clues in the history, physical examination, and radiographic studies can aid in the diagnosis. A patient in the third or fourth decade of life often will present with vague monoarticular complaints. Symptoms include intermittent, extreme deep pain localized to the hip, occasionally relieved by position. Decreased active and passive range of motion may be found. Small erosions in the head of the femur and acetabulum may occur early in the course of the disease. Magnetic resonance imaging is the imaging modality of choice and will show the characteristic findings of a joint effusion, synovial proliferation, and bulging of the hip. The synovial lining has a low signal on T1- and T2-weighted images, secondary to hemosiderin deposition. Pigmented villonodular synovitis should be included in the differential diagnosis of young patients with unexplained hip pain.

Surgical treatment options for cartilage defects within the knee

Injury to articular cartilage is increasingly diagnosed as a cause of knee pain. New surgical treatment options are now available to treat this clinical entity. Diagnosis is made easier by improved magnetic resonance imaging protocols that better visualize articular cartilage. On physical examination, patients at any age can have joint surface damage and primarily experience joint line tenderness and pain with activity. Treatment options include debridement of nonviable cartilage with abrasion or microfracture of the subchondral bone, transplantation of autologous osteochondral plugs, autologous chondrocyte transplantation, transplantation of cadaveric allogenic osteochondral grafts, and, for irreparable damage, total knee arthroplasty. These newer treatment options show promising early and intermediate results.

Early failure associated with the use of Hylamer-M spacers in three primary AMK total knee arthroplasties

We report 3 cases of early failure associated with AMK total knee arthroplasties with the use of Hylamer-M spacers. In 2 of these cases, massive osteolysis of the posterior condyles was noted; revision with the use of allograft bone to fill in the cavitary defects yielded excellent results. In all cases, large areas of pitting and delamination of the Hylamer spacers were noted. Given these cases and the previous literature on early failure of hip arthroplasties with Hylamer inserts, we recommend caution in using Hylamer for knee arthroplasty surgery.

Observer variation in the detection of acetabular bone deficiencies

To determine observer variation in the detection of acetabular bone deficiencies, 42 pairs of frontal (AP) and lateral hip radiographs and CT studies for total hip arthroplasty patients obtained within an average of 4 weeks of each other were reviewed separately by five radiologists and one orthopedic surgeon. Interobserver variations were calculated for each individual reading the films using kappa values. The individual film readings were then compared with a consensus reading of the CT data. When separate observers were analyzed, agreement on plain film readings was slight to fair (av. kappa = 0.1440 +/- 0.1047). The individual observers were not able to give readings which were very consistent with the CT consensus reading, resulting in a low sensitivity (65%) and specificity (74%) for acetabular defect classification with plain radiographs. The identification of acetabular bone defects from the AP and lateral views of the hip is highly subjective and variable from observer to observer.