Thirty-day mortality after elective hip and knee arthroplasty.

BACKGROUND: Hip and knee arthroplasties are very common operations in the UK with over 150,000 hip and knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors. METHODS: We looked at 30-day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was requested from the Information Services Division (ISD) and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who died within 30 days were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded. RESULTS: 12,243 patients underwent hip or knee arthroplasty within the study period. The male:female ratio was 2:3. The mean age was 68 with a range of 21-91. Ten patients died giving a 30-day mortality rate of 0.08%. The most common cause of death was myocardial infarction (7/10 patients). CONCLUSIONS: Our finding of a mortality rate of 0.08% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK.

Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur.

Previous studies on the timing of surgery for fracture of the hip provide conflicting evidence as to the effect of prolonged delay before operation. We have prospectively reviewed 3628 such fractures in patients older than 60 years of age. Those for whom the delay was for medical reasons were excluded. Patients were followed up for one year or until death. Operation was undertaken within 48 hours in 95.2% and after this in 4.8%. A significant increase in length of stay was found in patients operated on after 48 hours when compared with those in the earlier group (21.6 vs 32.5 days). No increase in hospital stay was found for lesser delays.

A rare case of irreducible knee dislocation in a seventy-three-year-old male.

Knee dislocations usually can be treated by closed reduction, although a small number must be reduced surgically. A seventy-three-year-old patient sustained a knee dislocation while skiing, with entrapment of the medial capsule and the medial retinaculum in the femoral notch. There was no evidence of any vascular or nerve injury. Open reduction with transverse dissection of the medial retinaculum led to reduction. We achieved an excellent result by external fixation and early aggressive rehabilitation without repair of the avulsed cruciate ligaments.

External fixation of lower limb fractures in children.

26 children with 29 lower limb fractures, between the age of 2 and 15 years, were treated with an external fixator. The average time to union and removal of the fixator was 71 days for femoral and 73 days for tibial fractures. Complications included pin problems in nine cases, two devices had to be replaced with a cast and one refracture. Leg length discrepancies were noted in five children and radiological malalignment in three. We recommend external fixation for all femoral shaft fractures and all open or dislocated tibial and tibia and fibula fractures beginning at the age of three to adolescence.

[Traumatic rupture of the inferior thyroid artery]. / Traumatische Ruptur der A. thyroidea inferior.

We report a rare case of traumatic aneurysma of the inferior thyroid artery, which occurred after a minor life-threatening trauma. The lesion was diagnosed during an angiographical examination, performed because of hemodynamic instability of the patient. For therapy, the lesion was ligated and excised.

[Associated injuries in severe pelvic trauma]. / Begleitverletzungen beim schweren Beckentrauma.

There has been a marked increase in the incidence of pelvic fractures over the last few years. Associated injuries to the urogenital and vascular system as well as nerve injuries worsen the prognosis. Over a five year period 126 patients with severe pelvic trauma were treated. Out of these 39 (30.9%) sustained additional peripelvic injuries and represent the study sample. Type B injuries according to the AO classification occurred in 16 (41%) patients, type C fractures in 23 (59%) patients. The spleen, liver and kidney were the most frequently injured organs (58.9%), followed by urogenital lesions (46.6%), nerve injuries (25.6%) and vascular lesions (15.3%). The most common extrapelvic lesions were thoracic injuries in 56.4% and severe head injuries (GCS < 8) in 33.3%. The mean Hannover Polytrauma score was 35.6 points, the mean Injury Severity Score 27.6 points. Osteosynthesis was performed in 21 pelvic ring fractures (53%), eight procedures (50%) in type B fractures and 13 (56%) in type C fractures. In type B injuries the anterior pelvic ring was stabilized with a tension band wiring in four cases, in two patients with an external fixator and with plate osteosynthesis in one case. In type C injuries the external fixator was applied as the only stabilizing procedure in six patients. In four cases the anterior ring was fixed with tension band wiring or plates and the dorsal aspect of the pelvic ring with sacral bars. Three patients had their additional acetabular fracture plated through a anterior approach. All surviving 28 patients were followed up for an average of 18 months (range 7-59 months) after the trauma. The patients were classified using the pelvic outcome score proposed by the German Society of Trauma Surgery. 53.4% of the type B fractures showed a good clinical outcome, 47.6% a poor outcome. 15.4% with type C fractures presented with a good outcome, 84.6% with a poor outcome. 80% of the type B and 23% of the type C fractures had a good radiological outcome. 20% of type B and 77% of type C injuries had a poor radiological outcome. Five patients (12.8%) sustained persistent urological symptoms. Three of these had urinary dysfunction, two used permanent cystotomies due to their severe neurological deficit after a head injury. Ten patients with nerve injuries at the time of trauma suffered long term neurological dysfunction of the lumbosacral plexus. The mortality rate was 28%. Seven patients died in the emergency room due to uncontrollable bleeding, four in the intensive care unit from multi-organ failure. The management of complex pelvic trauma consists of fracture treatment and interdisciplinary treatment of the associated injury. Lesions of the abdominal organs or of major vessels must be addressed first if hemodynamic instability is present. Injuries to smaller vessels can be embolized percutaneously. Urinary bladder ruptures are treated as an emergency, urethral lesions electively after four to six weeks. We recommend external fixation of the pelvis in the acute phase for control of both the osseous instability and control of haemorrhage through external compression. The treatment of choice for the anterior pelvic ring is tension band wiring or plating. If this is contraindicated due to an open fracture external fixation is the treatment of choice. Type C fractures require posterior ring stabilization which should be postponed until four days post admission.

[Gait analysis after intra-articular calcaneus fractures]. / Ganganalyse nach intraartikulären Fersenbeinfrakturen.

We retrospectively compared 20 patients with displaced intra-articular calcaneal fractures by clinical assessment and dynamic pedography. Eleven were treated operatively, 9 conservatively. The purpose was to identify differences in post-traumatic gait performance and to correlate the pedographic data to a clinical score to show its reliability. Twenty individuals without a history of foot injuries were used as a control group. Both groups had restricted motion in the subtalar joint, increased hindfoot and midfoot loading and decreased forefoot loading. Furthermore, they showed prolonged contact phases and an impaired ability to speed up gait during the toe-off phase. Load transfer from the hindfoot to the forefoot showed typical distribution patterns. The operatively treated group showed better functional results with fewer subjective complaints.

[Periprosthetic femur shaft fracture. Indications and outcome in 51 patients]. / Die periprothetische Femurschaftfraktur. Indikationen und Ergebnisse bei 51 Patienten.

Periprosthetic femoral fractures present the problem of fracture treatment and prosthetic stability. Various treatment options are recommended for managing these fractures. We treated 51 patients with 54 periprosthetic fractures between 1985 and 1995. Of these, 42 (78%) fractures were treated with a plate, eight (14%), with a revision prosthesis, two (4%), with retrograde nailing, and two (4%), conservatively due to poor medical condition. The choice of fracture management was dependent on the type and location of the fracture and on the stability of the prosthesis. A total of 50 fractures healed primarily. Complications included three cases of plate loosening, one further fracture, one deep infection, one broken bolt and one varus deformity. Four patients died in the postoperative period, an additional 19 were dead at the time of the evaluation. Fractures with a stable implant can be treated with plate fixation. Cases of a loose implant require revision. Distal fractures are stabilized with a plate or with a retrograde nail.

Femur fractures in patients with hip arthroplasty: indications for revision arthroplasty.

The number of periprosthetic femur fractures has increased due to the increase in the number of patients having total hip arthroplasty. In this study, we define indications for operative treatment in patients with femur fractures after hip arthroplasty. Fifty-three patients with 56 periprosthetic fractures were available for retrospective review of charts, radiographs, and physical examination; 42 fractures were treated with open reduction and internal fixation, 8 had replacement of hip prosthesis, 4 were treated with a retrograde genucephalic nail, and 2 patients were treated conservatively. The choice of treatment depended on the stability of the prosthesis and on the type and location of the fracture. Fifty-two fractures healed primarily. Three patients sustained a refracture, one an additional fracture, and two a deep infection. We recommend treatment with plate fixation for fractures without signs of prosthetic loosening. In fractures with loose implants, revision arthroplasty is required. Distal femoral fractures should be stabilized with a plate or with genucephalic nailing.

Scaphoid fractures: evaluation with high-spatial-resolution US initial results.

PURPOSE: To evaluate the diagnostic accuracy of high-spatial-resolution ultrasonography (US) in the diagnosis of scaphoid fractures. MATERIALS AND METHODS: In 72 hours after acute wrist trauma, 15 consecutive patients were examined for possible scaphoid fractures clinically and with conventional radiographs, including scaphoid views. Thereafter, high-spatial-resolution US was performed by two experienced radiologists blinded to the results of the previously performed investigations. High-spatial-resolution US of the scaphoid bones was performed from the palmar, lateral, and dorsal directions in the longitudinal and transverse planes. US findings indicative of a scaphoid fracture were cortical discontinuity and/or periosteal elevation. Finally, magnetic resonance (MR) images (short inversion time inversion-recovery, T1- and T2*-weighted) (ie, the standard) of the affected wrist were obtained and evaluated for a possible scaphoid fracture by two radiologists in consensus. RESULTS: Nine of 15 patients had scaphoid fractures. Seven (78%) of nine patients had positive findings at high-spatial-resolution US and five (56%) had such findings at conventional radiography (ie, four occult scaphoid fractures), with an accuracy of 87% and 73%, respectively. Two (50%) of four radiographically occult scaphoid fractures were depicted with high-spatial-resolution US. Sonographic findings of scaphoid fractures were either cortical discontinuity (n = 4), periosteal elevation (n = 2), or a combination of these two findings (n = 1). CONCLUSION: High-spatial-resolution US is a reliable diagnostic tool for the evaluation of occult scaphoid fractures and should be considered an adequate alternative diagnostic tool prior to computed tomography or MR imaging.