Hospital mortality after arthroplasty using a cemented stem for displaced femoral neck fractures.

PURPOSE: To review hospital mortality after hemiarthroplasty or total hip arthroplasty (THA) using a cemented stem for displaced femoral neck fractures. METHODS: Medical records of 284 hips in 70 men and 209 women aged 45 to 106 (mean, 81.3) years who underwent hemiarthroplasty (n=232) or THA (n=52) with a cemented stem using third-generation cementing techniques (including use of a plug, lavage, and cement pressurisation) for displaced femoral neck fractures were retrospectively reviewed. According to the American Society of Anesthesiologists (ASA) grading, 6 patients were classified preoperatively as grade 1, 77 as grade 2, 148 as grade 3, 47 as grade 4, and one as grade 5. Patients were operated on within 48 hours. Patients were rehabilitated in the hospital until discharge. The primary outcome measure was hospital mortality, including the cause of death. RESULTS: The mean length of hospital stay was 9.2 (standard deviation, 4.1) days. The hospital mortality was 5.7% (n=16). Of the 16 patients who died, 3 were classified preoperatively as ASA grade 2, 6 as grade 3, and 7 as grade 4. One patient died during the operation. One patient died in the recovery room within 6 hours. Both died from a cardiac arrest and were classified as ASA grade 4. Six patients died within the first 5 days. The causes of death were aspiration pneumonia (n=5), cardiac arrest (n=3), bowel perforation (n=2), multiple organ failure (n=3), type 2 respiratory failure (n=1), heart failure (n=1), and subarachnoid bleeding after a hospital fall (n=1). CONCLUSION: Hemiarthroplasty or THA using a cemented stem resulted in low hospital mortality in our hospital dedicated to the treatment of geriatric hip fractures. Hospital mortality was higher in patients with ASA grade 3 or higher.

Dedicated hip fracture service: implementing a novel model of care.

BACKGROUND: Hip fracture is a common clinical problem with historically high morbidity and mortality, and various model of acute and subacute care have been employed. We describe 12-month results from the first dedicated hip fracture unit in Australia, and compare it with other models of care both locally and internationally. METHODS: This was performed as a prospective uncontrolled study over a 12-month period. After application of exclusion criteria, a total of 346 patients were yielded. Outcomes measured included performance indicators as well as morbidity and mortality data. RESULTS: Improvements in performance indicators (adequate preoperative medical assessment, time to surgery, return to premorbid residence, etc.) and morbidity and mortality data (such as pressure sores, infections and in-hospital death) are noted. CONCLUSIONS: Early results suggest more comprehensive preoperative assessment, shorter times to theatre, reduced post-operative complications and diminished mortality rates when the principles undermining this unit are instituted.

Blood cultures for evaluation of early postoperative fever after femoral neck fracture surgery.

PURPOSE: To evaluate the utility of blood cultures in the assessment of early postoperative fever in hip fracture patients with no other indicators of sepsis. METHODS: 101 blood cultures were drawn on postoperative days 0 to 5 to investigate 84 febrile episodes in 31 women and 30 men (mean age, 80 years) whose body temperature measured via the tympanic route was ≥ 38 ºC. Culture results of these 61 patients were divided into culture-positive and culture-negative groups for comparison. RESULTS: Of the 101 blood cultures, only 2 were positive: one was obtained 5 days after dynamic hip screw fixation, and the other 4 days after hemiarthroplasty. Both blood cultures grew coagulase-negative staphylococcal species, which were deemed to be skin contaminants not requiring change of patient management. 44 of these patients were treated with oral or intravenous antibiotics for a period of time. CONCLUSION: The risk of bacteraemia in patients with postoperative fever but no other symptoms of infection is low. Routine procurement of blood cultures in such patients is ineffective and of limited utility.

Daptomycin resistance in prosthetic joint infections.

Antimicrobial resistance has been problematic since the advent of antibiotics. Patients with prosthetic joint infections often require prolonged courses of antibiotic therapy, with resistance commonly being the consequence. The rapid evolution of resistance poses a serious challenge in the treatment of infections and creates a need for new agents with novel mechanisms of bactericidal activity. Daptomycin, a cyclic lipopeptide naturally produced by Streptomyces roseosporus, is a newer agent approved for use in complicated skin, soft tissue, and prosthetic joint infections. To our knowledge, this article describes the first case of daptomycin-resistant heterogenous vancomycin intermediate-resistant Staphylococcus aureus (hVISA) in an 82-year-old man undergoing elective total knee arthroplasty in Queensland, Australia, with a subsequent deep prosthetic joint infection.A literature review is presented, and the increasing number of multi-resistant organisms and their implications for orthopedics are discussed. Worldwide reports of hVISA are reviewed. To our knowledge, this is the first article to describe daptomycin resistance in prosthetic joint infections. The role of newer antimicrobial agents, such as daptomycin, and strategies to minimize antibiotic resistance are examined.