Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission.

INTRODUCTION: Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED). METHODS: A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates. RESULTS:  Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions. CONCLUSION: Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) continues to be one of the most devastating diagnoses requiring emergent vascular intervention. There is a national trend toward increased use of endovascular procedures, with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed the treatment of AMI and the subsequent impact on length of hospitalization and hospitalization costs. METHODS: We identified all patients admitted for AMI from the National Inpatient Sample from 2004 to 2014 who received open surgical revascularization (OPEN) or an endovascular intervention (ENDO). Primary end points included length of hospital stay and cost of hospitalization. Our secondary end points included acute kidney injury (AKI), in-hospital mortality, and routine discharge. RESULTS: Among 10,381 discharges identified in the data set, 3833 (37%; 97.5% confidence interval [CI], 35%-39%) were male patients with a mean age of 69 years (range, 18-98 years); 4543 (44%; 97.5% CI, 41%-47%) patients were treated ENDO, and 5839 (56%; 97.5% CI, 53%-59%) patients were treated OPEN. Although a higher proportion of patients in the ENDO group (28%; 97.5% CI, 24%-31%) vs the OPEN group (14%; 97.5% CI, 11%-16%) had a moderate to severe Charlson Comorbidity Index (P < .0001), ENDO was associated with a lower mortality rate (12.3% [97.5% CI, 9.8%-14.8%] vs 33.1% [97.5% CI, 29.9%-36.2%]; P < .0001) and a lower mean hospitalization cost ($41,615 [97.5% CI, $38,663-$44,567] vs $60,286 [97.5% CI, $56,736-$63,836]; P < .0001). After propensity-adjusted logistic regression analysis, OPEN retained a significant association with higher mortality than ENDO (odds ratio, 3.0; 97.5% CI, 2.2-4.1) and with higher costs (mean, $9196; 97.5% CI, $3797-$14,595). Patients in the OPEN group had higher risk for AKI (P < .0001) and discharge to a skilled nursing facility (P < .0001) rather than home. CONCLUSIONS: Although the rate of ENDO continues to rise nationally, it still has not surpassed OPEN revascularization in the face of AMI. Patients treated endovascularly demonstrated one-third the rate of in-hospital mortality (odds ratio, 3.0; 97.5% CI, 2.2-4.1), an increased hazard ratio for discharge alive (hazard ratio, 2.27; 97.5% CI, 2.00-2.58), and a cost saving of $9196 (97.5% CI, $3797-$14,595) per hospitalization. Furthermore, they were less likely to develop AKI and to be discharged home after hospitalization.

Endovascular thoracic aortic transection repair has equivalent survival to open repair after blunt thoracic aortic injury.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is highly lethal and its management has evolved with the advent of endovascular approaches. We hypothesized that endovascular repair (ER) would have equivalent/improved survival compared to open repair (OR). The aim of our study was to review our center's morbidity and mortality after BTAI. METHODS: Our Level I trauma center registry was queried for BTAI between 2002-2015. This cohort was stratified into three groups: ER, OR and those patients managed non-operatively (NOP). Primary endpoint was mortality and secondary endpoints included complications after repair and freedom from re-intervention at follow-up. RESULTS: Among 81 patients with BTAI, there was a 58% mortality at presentation with a mean Injury Severity Score (ISS) of 65. From the remaining 34 patients alive after initial resuscitation, 12 (35%) patients were managed via OR, 12 (35%) via ER and 10 (30%) NOP. The mean ISS among these groups was 31, 44, and 30 respectively (P=0.6). 42% of patients in ER underwent coverage of the left subclavian artery without sequelae. There was one death in the OR and ER groups. Postoperative complications included one paraplegia after ER and one lower extremity weakness and vocal cord paralysis after OR. There was a shift in the year 2007 in the treatment of BTAI for ER instead of OR. Mean follow-up was 59.7±48.5months. None of the patients on follow-up required re-interventions. CONCLUSIONS: Although BTAI still carries a high mortality rate, data from our trauma center suggest that ER has equivalent survival when compared to OR.

Rehabilitación mínima aceledara en la reconstrucción del ligamento cruzado anterior / Minimal accelerated rehabilitation after reconstruction of anterior cruciate ligament

En un estudio de 21 pacientes operados por lesión de ligamento cruzado anterior y para reconstrucción artroscópica, se instaló un programa de rehabilitación sin uso de inmovilizaciones, con apoyo de la extremidad operada en el segundo día de postoperatorio sin muletas, no habiendo desanclaje o pérdida de los injertos y lográndose una extensión completa antes de 12 semanas de postoperatorio, con flexión superior a 120§, por lo cual lo recomendamos en pacientes con actividades comunes, pues el tiempo de recuperación y los costos del tratamiento disminuyen.

Artroscopía de la rodilla bajo anestesia local / Arthroscopy of the knee under local anestesia

Objetivo: Reportamos 74 casos de artroscopía de rodilla realizados bajo anestesia local. El procedimiento se realizó en 74 rodillas, 39 hombres (un caso fue bilateral) y 34 mujeres. Fueron 43 (58.10 por ciento) rodillas derechas y 31 (41.89 por ciento) izquierdas. Edad promedio de 38 años.Se incluyeron todas las cirugías de rodilla realizadas bajo anestesia local con xilocaína, 20 cc al 2 por ciento registrando el tiempo quirúrgico, la presencia de dolor, el o los procedimientos realizados correlacionando el diagnóstico preoperatorio y artroscópico. No usamos isquemia.El tiempo quirúrgico promedio fue de 35 minutos (17 a 120). En 54 pacientes (72.79 por ciento) no hubo dolor, en 13 pacientes (17.58 por ciento) fue mínimo y 6 pacientes requirieron sedación. Realizamos un procedimiento quirúrgico en 32 casos (43.24 por ciento), dos procedimientos en 32 casos (43.24 por ciento) y, tres o más procedimientos en 10 (13.51 por ciento). El diagnóstico preoperatorio fue correcto en 44 casos (59.45 por ciento), parcialmente correcto en 22 casos (29.72 por ciento) e incorrecto en 8 (10.81 por ciento).Por el dolor transoperatorio consideramos que los resultados fueron excelentes en 54 pacientes (72.79 por ciento), regulares en 13 pacientes (17.58 por ciento) y malos en 6 pacientes (8.1 por ciento).

Plicatura artroscópica del ligamento peroneo-astragalino anterior: una nueva técnica artroscópica / Arthroscopy plicature of the talo-fibular ligament: a new arthroscopic technique

Se presenta un método de plicatura artroscópica de tobillo en la lesión del ligamento peroneo- astragalino anterior (LPAA) haciendo énfasis en la necesidad de revisar las patologías intraarticulares que se asocian a dichas lesiones. El estudio incluye 16 casos; de estos se detectaron tres (18 por ciento) con patología intraarticular. Se llevó un seguimiento con una media de 23.8 meses (de 6 meses a 4 años) y solamente se encontró una recaída en uno solo de ellos (6.25 por ciento) lo que representa un 93.75 por ciento de éxitos lo cual se compara con la cirugía abierta que presenta una eficacia de 80 por ciento pero con una mayor morbilidad y lesionando mayor tejido sano, siendo el intervalo de confianza de 0.83 a 1, con una p < 0.05

Plicatura del ligamento peroneoastragalino anterior del tobillo: una nueva técnica artroscópica / Plasty of talofibular ligament of the ankle: a new arthroscopic technique

Se presenta un método de plicatura artroscópica de tobillo en la lesión del ligamento fibulotalar anterior (LFTA) haciendo énfasis en la necesidad de revisar las patologías intrarticulares que se asocian a dichas lesiones. El etudio incluye 16 casos; de éstos, se detectaron tres (18 por ciento) con patología intraarticular. Se llevó un seguimiento con una media de 23.8 meses (de 6 meses a 4 años) y solamente se encontró una recaída en un solo de ellos (6.25 por ciento) lo que representa un 93.75 por ciento de éxitos, lo cual se compara con la cirugía abierta que presenta una eficacia de 80 por ciento pero con mayor morbilidad y lesionando mayor tejido sano, siendo el intervalo de confianza de 0.83 a 1, con una p < a 0.05

Plastías ligamentarias en lesiones del ligamento cruzado anterior usando la guía de Iñigo-Pavlovich / Ligamentary plasties in anterior cruciate ligament injuries using Iñigo-Pavlovich guide

El presente trabajo es prospectivo, longitudinal y comparativo sobre la utilidad que tiene la guía de Iñigo-Pavlovich en las plastías ligamentarias substitutivas para la reconstrucción del ligamanto cruzado anterior. El universo de trabajo está constituido por 36 pacientes atendidos en el Hospital de Urgencias Traumatológicas del Instituto Mexicano del Seguro Social, observando clara prevalancia en el sexo masculino y mayor frecuencia en la tercera década de la vida. Con el uso de esta guía, obtuvimos una disminución en el tiempo quirúrgico promedio debido a que con la guía es más fácil localizar los puntos isométricos femoral y tibial; el labrado de los túneles tibial y femoral se hacen en forma simultánea y en dirección similar, lo que abate el tiempo de perforación y al ser mono-túnel, el paso subsecuente del injerto es más sencillo. No se presentaron complicaciones o fallas inherentes a la guía