Incomplete Periprosthetic Atypical Femoral Fracture With Concomitant Hip and Knee Arthroplasties: A Case Report.

CASE: We present a case of an incomplete periprosthetic femoral fracture at the mid-distal third of the femoral stem after 11 months of bisphosphonate use. It is 1 of 4 cases of mid-distal periprosthetic atypical femoral fractures (PAFFs) found in our literature review. She was treated with protected weight-bearing, cessation of bisphosphonates, and teriparatide. Eighteen months after diagnosis, follow-up radiographs showed a bridging callus and reduction of a transverse fracture line. CONCLUSION: The incomplete PAFF was contributed by both decreased bone turnover from bisphosphonate use and increased mechanical stress at the lateral femoral cortex. Her previous left bipolar hemiarthroplasty and subsequent Total Knee Arthroplasty shifted the mechanical alignment medially, hence increasing tensile stress.

End stage renal disease patients undergoing hip fracture surgery have increased length of stay, acute hospital bill size, and reduced survivorship-implications on a bundled care program.

End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rates. As these patients significantly skew healthcare financing in a bundled care payment (BCP) program, a risk stratified approach to BCPs could be done to take into account the difference in resources required. INTRODUCTION: End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rate. Hip fracture patients with ESRD may significantly skew healthcare financing in a bundled care payment (BCP) program. MATERIALS AND METHODS: ESRD patients undergoing hip fracture surgery from June 2007 to June 2012 within a tertiary hospital in Singapore were identified and matched to two other controls without ESRD based on secondary features of sex, age, fracture type, and surgery performed. Data was collected for American Society of Anesthesiologist (ASA) score, duration of surgery (DOS), length of stay (LOS), 30-day and 1-year mortality, and the presence of 10 other comorbidities: diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), ischemic heart disease (IHD), arrhythmia (ARR), cerebrovascular disease (CVA), dementia (DEM), asthma (ASTH), peripheral vascular disease (PVD), and anemia (ANE) from electronic medical records. Costs were retrieved from the gross acute hospitalization bill. RESULTS: Forty-one ESRD patients were successfully matched with 82 controls. Patients with ESRD had higher ASA scores (3 vs 2, p = 0.0001), had 75% higher LOS (21 vs 12 days, p < 0.0001), were associated with 67% higher healthcare expenditure (median $20542 vs $12236, p < 0.0001), and 1-year mortality (OR: 19.6, p < 0.0001). ESRD patients had an average of 4.1 comorbidities per patient compared to 1.84 in the control group. CONCLUSION: ESRD is an outsized factor on the outcome of hip fracture patients who have markedly higher and more variable healthcare utilization.

Early Postoperative Pain After Total Knee Arthroplasty Is Associated With Subsequent Poorer Functional Outcomes and Lower Satisfaction.

BACKGROUND: There are few studies investigating the effects of acute postoperative pain on functional outcomes after total knee arthroplasty (TKA). The aims of this study are to identify perioperative factors associated with increased early postoperative pain and investigate the effects of acute postoperative day 1 and 2 pain on outcomes at 6 months and 2 years post-TKA. METHODS: 1041 unilateral TKA patients were included in this retrospective cohort study. Patients were categorized into minor (visual analog scale: VAS <5) and major (VAS ≥5) pain groups based on postoperative day 1/2 VAS scores. Patients were assessed preoperatively, at 6 months and 2 years using Knee Society Knee Score and Function Scores (KSFS), Oxford Knee Score (OKS), SF-36 physical and mental component score (SF-36 PCS), expectation and satisfaction scores. Perioperative variables including age, gender, race, body mass index, American Society of Anesthesiologist status, type of anesthesia, and presence of caregiver were analyzed as predictors of postoperative acute pain. Wilcoxon two-sample test was used to analyze outcomes significantly associated with "major pain." Multiple logistic regression was used to identify predictors of "major pain." RESULTS: Patients with "minor pain" had significantly better KSFS, Knee Society Knee Score, OKS, and SF-36 PCS scores at 6 months and significantly better KSFS, OKS, SF-36 PCS, and satisfaction at 2 years (P < .05). A significantly higher percentage of patients with "minor pain" met the minimal clinically important difference for SF-36 PCS at 6 months and KSFS at 2 years (P < .05). Women, Indian/Malay race, higher BMI, and use of general over regional anesthesia were independent predictors of getting "major pain" (P < .05). CONCLUSION: Patients should be counseled about risk factors of postoperative pain to manage preoperative expectations of surgery. Patients should be managed adequately using multimodal pain protocols to improve subsequent functional outcomes while avoiding unnecessary opioid use.

End-Stage Renal Failure Is an Independent Risk Factor for 1-Year Mortality After Hip Fracture Surgery.

INTRODUCTION: End-stage renal failure (ESRF) with its associated comorbidities increase postoperative mortality in hip fracture patients. This study investigated the association of ESRF with various comorbidities in patients on dialysis and assessed rates ESRF as an independent risk factor for all-cause postoperative 1- year mortality rates. METHODS: This was a retrospective cohort study on patients aged 55 years and older who underwent their first nonpathological, low-energy hip fracture surgery at an Asian tertiary hospital from June 2007 to 2012. Patients were identified as cases with ESRF on dialysis (study group) or non-ESRF patients (controls). Various comorbidity factors and postoperative 1-year mortality status were obtained from institutional electronic medical records. Univariate and multivariate logistic regression were used to identify significant risk factors for all-cause, 1-year mortality. RESULTS: With no loss to follow-up, the 1-year postoperative mortality rate was 19.6% for the 46 patients with ESRF on dialysis and 8.4% for non-ESRF controls (P = .028). Fisher exact test showed that hypertension, ischemic heart disease (IHD), diabetes mellitus (DM), anemia, cerebrovascular disease, and vascular disease were significantly associated with ESRF (P < .05). Multivariable logistic regression analysis identified ESRF (adjusted odds ratio[AOR] = 2.85, P = .021), cancer (AOR = 3.04, P = .003), IHD (AOR = 2.07, P = .020), DM (AOR = 2.03, P = .022), and age (AOR = 1.08, P <.0001) as independent risk factors for 1-year mortality following hip fracture surgery. The area under the receiver-operating characteristic curve (95% confidence interval) for the multivariable predictor of 1-year mortality was 0.75 (0.60-0.82). CONCLUSIONS: Although associated with multiple comorbidities, ESRF was found to be independently predictive of 1-year mortality in patients undergoing hip fracture surgery, second to cancer in terms of magnitude of risk posed. As ESRF is a negative prognostic factor for 1-year mortality after hip fracture surgery, its importance should be recognized with implications on preoperative counseling to patients about the increased risk and implications on fracture prevention.

Sorafenib and bevacizumab for recurrent metastatic hepatoblastoma: stable radiographic disease with decreased AFP.

We report the use of sorafenib and bevacizumab in combination for a patient with recurrent metastatic hepatoblastoma (HB). This combination demonstrated activity against our patient's refractory HB that had been extensively treated with multiple prior chemotherapeutic regimens. The patient had stabilization of radiographic disease coupled with an 83% decrease in his alpha-fetoprotein level. Given the response in this setting and the paucity of other available options, consideration could be given to using this combination as therapy in patients with recurrent HB who have failed more traditional agents.

Pancytopenia induced by hypothermia.

Hypothermia has been demonstrated to induce pancytopenia in animals, but whether this association exists in humans is unknown. The authors report the case of an 8-year-old girl in whom hypothermia (temperature 33 degrees C-35 degrees C) is the cause of pancytopenia. The patient developed thermoregulatory dysfunction subsequent to surgical resection of a craniopharyngioma. Her recurrent cytopenias could not be explained by any etiology except chronic hypothermia. The pancytopenia improved upon rewarming the patient to a temperature of 36 degrees C. This association between hypothermia and pancytopenia has rarely been reported in humans and may be underdiagnosed especially in cases of transient or milder presentations. The authors recommend careful hematologic monitoring of patients with thermoregulatory dysfunction.

Thalassemia: current approach to an old disease.

This article discusses the approach for recognition, diagnosis, and management of the thalassemias, and reviews new prospects of therapy, focusing mostly on the beta-thalassemias--the more severe and clinically important type, beta-thalassemia major is typically treated with regular transfusion and chelation therapy. New strategies for specific therapy including monitoring of iron induced organ damage, fetal hemoglobin augmentation as an alternative for transfusions, bone marrow transplantation offer hope for prevention of complications and better care of the beta-thalassemias.