Patient-specific factors affecting survival following hip fractures-a 14-year follow-up study in Finland.

The mortality of elderly hip fracture patients is high. Eighty-five percent of all patients were followed until death. The three most protective factors for 1-year survival were ASA class; BMI; and age, and the four most protective factors for 14-year survival were age; BMI; ASA class; and subtrochanteric fracture type. OBJECTIVE: Hip fractures are associated with increased mortality. The purpose of this study was to evaluate the protective preoperative factors regarding the survival of short-term (1 year) and long-term (14 years) follow-up in a hip fracture cohort in Finland. METHODS: A total of 486 patients, operated on in 2005 and 2006, were retrospectively evaluated. Survival was analyzed using Bayesian multivariate analysis and relative survival with the life table method. All patients were followed for a minimum of 14 years. RESULTS: We analyzed 330 women and 156 men, whose mean ages were 82.4 and 72.0 years, respectively. The overall mortality rate was 7% at 1 month, 22% at 12 months, and 87% at 14 years. Protective factors against mortality at 1 year were ASA class (1-3), BMI ≥ 20 kg/m2, age < 85 years, alcohol involvement, Alzheimer's disease, no comorbidities, certain operative methods, and female sex. Factors promoting survival at 14 years were age < 75 years, BMI ≥ 20 kg/m2, ASA class (1-2), subtrochanteric fracture, certain operative methods, alcohol involvement, and no comorbidities. CONCLUSIONS: Protective factors for 1-year survival in order of importance were ASA class, BMI, and age, and, correspondingly, for 14-year survival, age, certain operative methods, BMI, and ASA class. The relative survival of hip fracture patients was lower than that of the general population.

Glucose management team significantly improves glycaemic care and commitment to in-hospital guidelines within arthroplastic patients.

BACKGROUND: Perioperative dysglycaemias are a risk for harm but guidelines to improve glucose management are poorly adhered to. AIM: To determine whether a specialized team and diabetes education improves the implementation of guidelines and glucose values. METHODS: We conducted a prospective study of 611 nonselected, consecutive patients attending for elective hip or knee arthroplasty. The first 209 patients received conventional care and the following 402 patients received intervention (Acute Glucose Service, AGS) in two chronological groups; either perioperatively (AGS1) or also preoperatively (AGS2). The AGS-team provided diabetes education, identified the patients with diabetes risk and adjusted the medication when needed. Capillary plasma glucose (CPG) was repeatedly measured and glycated haemoglobin (HbA1c) obtained before and after the surgery. The study objectives were to evaluate the staff actions when hyperglycaemia was severe (CPG >10 mmol/L), and to assess improvement of the glycaemic values and the complication rate within 3 months. RESULTS: None of the severely hyperglycaemic events in the reference group were treated according to guidelines. In the AGS 1 group, 50% and in the AGS2 group, 53% were appropriately managed (p < .001). The events of hyperglycaemia (CPG >7.8 mmol/L at least twice) and of severe hyperglycaemia (CPG >10 mmol/L) decreased in all patient groups. The medians of the highest, mean and variability of CPG values improved. The mean HbA1c improved significantly within AGS 2. There was no association between improved glycaemic care and early complications. CONCLUSIONS: AGS intervention significantly improves adherence to guidelines and glucose values.

Perioperative hyperglycaemia in elective arthroplasties. Should we do better?

BACKGROUND: Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty. METHODS: Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed. RESULTS: A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (>10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%) >10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c < 42 mmol/mol and random plasma glucose < 7.8 mmol/l. Of the 84 hyperglycaemic episodes > 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed. CONCLUSIONS: Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists. CLINICAL TRIAL REGISTRATION: Clinical trials, gov. NCT03306810.

Natural coniferous resin salve used to treat complicated surgical wounds: pilot clinical trial on healing and costs.

Resin is a natural product of coniferous trees. Salves manufactured from spruce resin (Picea abies) have been used for centuries to treat wounds and skin infections. We report a pilot clinical trial designed to investigate healing rates, factors that contribute to delayed wound healing, cost-effectiveness, and incidence of allergic reactions when resin salve is used to treat complicated surgical wounds. The trial involved 23 patients in whom wound healing after surgery was delayed. These patients were assigned to resin salve treatment. The primary outcome measure was the number of days to complete wound healing. Secondary objectives included an assessment of factors contributing to delayed wound healing, an estimation of associated costs, and an investigation into the occurrence of allergic reactions related to resin salve therapy. The study achieved a healing rate of 100%. The mean ± SD healing time was 43 ± 24 days. The mean ± SD wound size (length × width × depth) was (29 ± 19) × (12 ± 7) × (4 ± 3) mm. Wound size, use of corticosteroids or other immunosuppressants, and immobilization were statistically significant (P < 0.05) contributors to delayed wound healing and impaired re-epithelialization. The total mean ± SD costs of the resin salve treatment were €45.0 ± 26.0 per patient during the entire treatment period and €1.2 ± 0.5 per treatment day. The rate of allergic reactions was 0%. The results of this pilot trial indicate that complicated surgical wounds may be treated successfully with resin salve. The treatment method is clinically effective and cost-effective, and the rate of allergic reactions is low.

Reconstruction of the trapeziometacarpal joint in inflammatory joint disease using interposition of autologous tendon or poly-L-D-lactic acid implants: a prospective clinical trial.

Interposition arthroplasty with bioreplaceable poly-L-D-lactic acid (PLDLA) implants has yielded promising results in reconstruction of rheumatoid hands. In this prospective clinical study we compared the PLDLA implant arthroplasty (n = 17) with that of tendon interposition (n = 12) for destruction of the trapeziometacarpal joint in arthritic patients. There was no significant difference between the two groups preoperatively. At one-year follow-up, the mean pain and function scores were 5 and 13 in the PLDLA group, and 19 and 43 in the tendon interposition group, respectively. At one-year follow-up the visual analogue scale (VAS) for function of the PLDLA group differed significantly from that of the tendon interposition group (p = 0.03). This difference was not found at three months postoperatively, and disappeared again at two-year follow-up. Otherwise, no significant difference was found between the groups in the pain or function scores, functional tests, or range of movement. Bioreplaceable interposition arthroplasty works at least as well as tendon interposition. The operation is easier.

High rate of osteolytic lesions in medium-term followup after the AES total ankle replacement.

BACKGROUND: Some previous studies have shown a high percentage of early-onset and rapidly progressing osteolysis associated with total ankle arthroplasty (TAA) by the Ankle Evolutive System (AES). The purpose of our study was to analyze medium-term results at our institution. MATERIALS AND METHODS: Altogether 38 TAAs using AES prostheses were carried out between 2003 and 2007. Diagnoses were rheumatoid arthritis (71%), post-traumatic and idiopathic osteoarthritis (29%). The mean age was 54 years, followup 28 months. Tibial and talar components had hydroxyapatite coating on metal (Co-Cr) components (HA-coated). Since 2005 the design was changed and components were porous coated with titanium and hydroxyapatite (dual-coated). RESULTS: Two-year survival was 79% (95% CI: 56 to 98). At followup 34 (89%) primary tibial and talar components were preserved. In 19 (50%) TAAs osteolysis (more than or equal to 2 mm) occurred in the periprosthetic bone area and in nine (24%) comprised large "cyst-like osteolysis''. In HA-coated prostheses radiolucent lines (less than or equal to 2 mm) or osteolysis (more than or equal to 2 mm) were detected in 11 (100%) cases and in dual-coated prostheses in 19 (74%) (p = 0.08). On the other hand there was more large "cyst-like osteolysis'' around the dual-coated prosthesis and lesions were larger (p = 0.017). In rheumatoid arthritis osteolysis was detected in 14 (52%) and large "cyst-like osteolysis'' in seven (26%) prostheses and in the group of traumatic and idiopathic osteoarthritis in six (55%) and two (18%), respectively. CONCLUSION: This study showed a high frequency of osteolysis in medium-term followup after the AES ankle replacement. The outcome was not sufficiently beneficial and we have discontinued use of this prosthesis.

Comparison of bioreplaceable interposition arthroplasty with metatarsal head resection of the rheumatoid forefoot.

BACKGROUND: Interposition arthroplasty with bioreplaceable poly-L/D-lactic acid (PLDLA) implants has been studied in Finland with promising results in reconstruction of the rheumatoid hand. We evaluated this material in a series of patients with rheumatoid forefoot deformities. MATERIALS AND METHODS: Thirty-five patients were randomized to either PLDLA metatarsophalangeal joint interposition arthroplasty group (16 patients) or to conventional metatarsal head resection group (19 patients). RESULTS: At 3 months after surgery, the function VAS was significantly better in the control group (p = 0.003). The difference disappeared by 12 months. Otherwise, comparison between the two groups did not reveal any statistically significant differences in the AOFAS scores or the pain VAS at 3 or 12 months. CONCLUSION: Early results after PLDLA interposition arthroplasty of metatarsophalangeal joints were not as promising as previously reported with rheumatoid metacarpophalangeal reconstruction.