Intraoperative Hemodynamic Instability and Higher ASA Classification Increase the Risk of Developing Non-Surgical Complications following Orthopedic Surgeries.

(1) Background: Either pre-operative physical status or unstable hemodynamic changes has been reported to play a potential role in causing vital organ dysfunction. Therefore, we intended to investigate the impact of the American Society of Anesthesiologist (ASA) classification and intraoperative hemodynamic instability on non-surgical complications following orthopedic surgery. (2) Methods: We collected data on 6478 patients, with a mean age of 57.3 ± 16, who underwent orthopedic surgeries between 2018 and 2020. The ASA classification and hemodynamic data were obtained from an anesthesia database. Non-surgical complications were defined as a dysfunction of the vital organs. (3) Results: ASA III/IV caused significantly higher odds ratios (OR) of 17.49 and 40.96, respectively, than ASA I for developing non-surgical complications (p < 0.001). Non-surgical complications were correlated with a 20% reduction in systolic blood pressure (SBP), which was intraoperatively compared to the pre-operative baseline ((OR) = 1.38, p = 0.02). The risk of postoperative complications increased with longer durations of SBP < 100 mmHg, peaking at over 20 min ((OR) = 1.33, p = 0.34). (4) Conclusions: Extended intraoperative hypotension and ASA III/IV caused a significantly higher risk of adverse events occurring within the major organs. The maintenance of hemodynamic stability prevents non-surgical complications after orthopedic surgeries.

Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac-Transsacral Screw Fixation in Normal and Dysmorphic Sacra.

Transiliac-transsacral screw fixation is widely used to stabilize unstable posterior pelvic ring injuries. Preoperative radiographic assessment of the safe osseous corridor is necessary because the safe space of sacrum is narrower for transiliac-transsacral screw placement than for traditional iliosacral screw placement. However, the radiographic assessment has rarely been studied in the Taiwanese population. We retrospectively analyzed 100 patients with pelvic computed tomography images and divided them into normal and dysmorphic pelvis groups. To determine the safe osseous space, we recorded cross-section area, cross-sectional diameter of the safe zone (CS-szD), and safe zone width on axial view (Ax-szW) in the S1 to S3 segments. The prevalence of dysmorphic pelvis was 48% among all patients. In the S1 segment, no differences were found in the cross-section area and CS-szD been the two groups. However, the Ax-szW was significantly smaller in the dysmorphic pelvis group. In the S2 segment, the cross-section area, CS-szD, and Ax-szW were all significantly larger in the dysmorphic pelvis group. In the S3 segment, the cross-section area and CS-szD of the normal pelvis group were both significantly smaller. No differences were found in the Ax-szW between the two groups. Based on our findings in a Taiwanese population, S1 was the most suitable segment for transiliac-transsacral screw fixation in a normal pelvis, whereas S2, followed by S3, was most suitable in a dysmorphic pelvis. This study offers surgeons information on identifying the optimal sacral segment for transiliac-transsacral screw placement for each pelvic morphology. [Orthopedics. 2024;47(1):e13-e18.].

Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries.

Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.

Complications of Unilateral Biportal Endoscopic Lumbar Discectomy: A Systematic Review.

OBJECTIVE: In recent years, biportal endoscopic surgery has gained popularity, and the number of publications on it has also increased. We herein aimed to investigate the complications of biportal endoscopic surgery. In this study, the available literature was reviewed systematically and the published complications of discectomy in biportal endoscopic spinal surgery were summarized. METHODS: A systematic search of the literature published until December 31, 2021, was performed using the PubMed, Cochrane Library, Embase, and Web of Science databases. Studies on spinal discectomy using the biportal method were included. RESULTS: Twenty-two articles were finally included for review. The reported complication rate of this procedure was 0%-23.6% (radiological hematoma). In most studies, the complication rate was less than 11%. The mean complication rate was 5.37% when 596 patients (from 16 studies) underwent unilateral biportal endoscopic discectomy for the treatment of lumbar disk herniation. The reported complications of this procedure included dural tear, hematoma, incomplete decompression, recurrence, instability, neurological complications (post-op paresthesia, dysthesia or numbness, or root injury), pseudomeningocele, ascites, infection, retinal hemorrhage, and burn injury. The complication rate was higher in the early learning curve. CONCLUSIONS: Unilateral biportal endoscopic discectomy has an acceptable complication rate. Knowing the possible complications and risks of this procedure could help surgeons in taking measures to avoid common complications.

Predicting in-hospital mortality for dementia patients after hip fracture surgery - A comparison between the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index.

BACKGROUND: Considerable in-hospital mortality was reported in geriatric patients with dementia sustaining femoral neck or inter-trochanteric fracture. We intended to establish a predictive model of in-hospital mortality for dementia patients after hip fracture surgery. METHODS: We collected 8080 registrants ≧ 65 years old from the subset (LHID2000) of the National Health Insurance Research Database (NHIRD) that met the following inclusion criteria:1. Admitted with the ICD of hip fracture; 2. Underwent operation of hip fracture during the same hospitalization; 3. Co-existing diagnosis of dementia (ICD-9-CM codes 290). The co-morbidity was recorded according to validated Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) from the diagnoses of hospitalization. The main outcome measure was in-hospital mortality that was defined as death being reported during hospitalization. The comparison of predictability was conducted by Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) among different predictive models. RESULTS: The Charlson Comorbidity Index (CCI) score and Elixhauser Comorbidity Index (ECI) score showed similar ability in predicting in-hospital mortality (AUC = 0.653, 95% CI = 0.611-0.695 for CCI; AUC = 0.624, 95% CI = 0.582-0.665 for ECI, p = 0.0717). By adding age grouping (≥80 yrs = 1, 65-80 yrs = 0) and gender difference (Male = 1, Female = 0), these two models were shifted to models CCI_new1 and ECI_new1. Consequently, the AUC greatly increased in the CCI_new1 (AUC = 0.682, 95% CI = 0.643-0.722). It therefore provided better prediction of in-hospital mortality than ECI_new1 (AUC = 0.651, 95% CI = 0.611-0.691) (p = 0.0444). CONCLUSIONS: Utilizing the CCI with addition of grouping for age and gender provides a better prediction for in-hospital mortality than the ECI among elderly patients with concomitant dementia and hip fracture who underwent surgical intervention.

A118G polymorphism of OPRM1 gene caused different morphine consumption in female patients after total knee replacement.

BACKGROUND: We intended to clarify the effect of gender and A118G polymorphism of Opioid Receptor µ1 (OPRM1) on the required morphine for patients to maintain Visual Analogue Scale â‰¦ 3 for post-operative pain control after total knee replacement (TKR). METHODS: With approval from Institutional Review Board (IRB) and obtainment of informed consents, 111 patients undergoing primary TKR were enrolled without violating the exclusion criteria, including previous history of allergy to morphine, alcohol or substance abuse, use of psychotropic medications, morbid obesity of body mass index (BMI) > 40 kg/m2, chronic pain with evidence of central sensitization, and uncooperative use of patient controlled analgesia (PCA) device. The amount of PCA-delivered morphine for pain control and the 'demand' (the count of button pushing for requiring pain medication from PCA) were recorded at 3, 6, 12, 24, 36, 48 and 72 h after the operation. One-way ANOVA with post-hoc test by Scheffe's method was adopted for statistical analysis of each variant (AA, AG, GG). The side-effects (nausea, vomiting and sedation) from morphine were recorded. P < 0.05 was considered to be statistically significant. RESULTS: With sequencing by ABI PRISM 310 Genetic Analyser, we disclosed that the allele frequency was 75.5% for the A allele (female: 77.5%, male: 69.6%) and 24.5% for the G allele (female: 22.5%, male: 30.4%). The frequency of genotype occurrence was 61.3% for AA, 24.3% for AG and 14.4% for GG. Female patients of homozygous G118G of OPRMI required more morphine from PCA device for post-operative pain control than patients of AA and AG genotypes. No significant difference in morphine consumption for post-operative pain control was disclosed among three genotypes for male patients. CONCLUSIONS: The impact caused by G118G polymorphism of OPRM1 on requirement of morphine consumption for post-operative pain control is potentially gender-linked.

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy.

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, -3.7° (18.0%) for the Thomas test, -15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.

Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique.

INTRODUCTION: Ankle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet. PATIENTS AND METHODS: We prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT. RESULTS: All patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT. CONCLUSIONS: WALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.

Intraoperative blood transfusion predicts postoperative delirium among older patients undergoing elective orthopedic surgery: A prospective cohort study.

OBJECTIVES: To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery. METHODS: This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis. RESULTS: Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates. CONCLUSIONS: Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.

Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial.

PURPOSE: To prospectively compare the efficacy of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) with a sham control group (normal saline solution [NS]) for knee osteoarthritis in a randomized, dose-controlled, placebo-controlled, double-blind, triple-parallel clinical trial. METHODS: A total of 87 osteoarthritic knees (53 patients) were randomly assigned to 1 of 3 groups receiving 3 weekly injections of either leukocyte-poor PRP (31 knees), HA (29 knees), or NS (27 knees). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and International Knee Documentation Committee (IKDC) subjective score were collected at baseline and at 1, 2, 6, and 12 months after treatment. Data were analyzed using generalized estimating equations. RESULTS: All 3 groups showed statistically significant improvements in both outcome measures at 1 month; however, only the PRP group sustained the significant improvement in both the WOMAC score (63.71 ± 20.67, increased by 21%) and IKDC score (49.93 ± 17.74, increased by 40%) at 12 months. For the intergroup comparison, except for the first month, there was a statistically significant difference between the PRP and NS groups in both scores throughout the study duration (regression coefficients of 8.72 [P = .0015], 7.94 [P = .0155], and 11.92 [P = .0014] at 2, 6, and 12 months, respectively, for WOMAC score, and 9.1 [P = .0001], 10.28 [P = .0002], and 13.97 [P < .0001], respectively, for IKDC score). There was no significant difference in both functional outcomes between the HA and NS groups at any time point. Only the PRP group reached the minimal clinically important difference in the WOMAC score at every evaluation (15%, 21%, 18%, and 21% at 1, 2, 6, and 12 months, respectively) and the minimal clinically important difference in the IKDC score at 6 months (improvement of 11.6). CONCLUSIONS: Intra-articular injections of leukocyte-poor PRP can provide clinically significant functional improvement for at least 1 year in patients with mild to moderate osteoarthritis of the knee. LEVEL OF EVIDENCE: Level I, randomized controlled single-center trial.

Different impacts of dementia on two-year mortality after osteosynthesis and hemiarthroplasty in treating geriatric hip fractures.

BACKGROUND: Geriatric hip fractures are mostly managed by internal fixation (IF) or hemiarthroplasty (HA). Survivorship of dementia patients following these surgeries has not been extensively compared in literature. By analysis of nationwide database, this study aimed to investigate the impact of dementia on two-year mortality after IF and HA in treating geriatric hip fractures. METHOD: From retrospective review of Taiwan's National Health Insurance Research Database, we enrolled 153,623 subjects aged 65 years and older with hospitalization for first hip fracture operated by IF (93,029 cases) or HA (60,594 cases) between 2000 and 2011. Postoperative mortality was compared between subjects with and without dementia after adjustments of age, gender, Charlson comorbidity index and hospital level. RESULTS: The prevalence of dementia was 5.24% in the IF and 5.29% in the HA group. In the IF group, dementia increased adjusted hazard ratio of one-year (1.06, 95%CI:1.00-1.13) and two-year mortality (1.10, 95%CI:1.05-1.16). However, short and long-term mortality following HA was not significantly impacted by dementia (in-hospital OR:0.79, 95%CI:0.60-1.03; three-month HR:0.99, 95%CI:0.87-1.12; one-year HR:1.01, 95%CI:0.93-1.10; two-year HR:1.03, 95%CI:0.96-1.09). In a subgroup of dementia patients, mortality following IF was 15% higher than HA in one (p = 0.004) and two years (p < 0.001). The negative prognostic factors included female (HR:1.10; 95%CI:1.03-1.18) and aging 65-84 years (HR:1.15; 95%CI:1.00-1.32). CONCLUSION: Dementia increased one and two-year mortality following geriatric hip fracture treated by IF, rather than HA. Dementia patients undergoing HA, especially female or 65-84 years old, sustained better one and two-year survival than those receiving IF.

WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.

BACKGROUND: The wide-awake local anesthesia no tourniquet (WALANT) technique is applied during various hand surgeries. We investigated the perioperative variables and clinical outcomes of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT. METHODS: From January 2015 to January 2017, 60 patients with distal radius fractures were treated, and 24 patients (40% of all) were treated with either a volar or a dorsal plate via WALANT procedure. Of these 24 patients, 21 radius fractures were fixed with a volar plate, and the other 3 were fixed with a dorsal plate. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated. RESULTS: One of the 24 patients could not tolerate the WALANT procedure and was reported as a failed attempt at WALANT. In the cohort, 23 patients successfully received distal radius ORIF under WALANT procedure. The average age is 60.9 (range, 20-88) years. The average operation time was 64.3 (range, 45-85) minutes, the average blood loss was 18.9 (range, 5-30) ml, and the average of duration of hospitalization is 1.8 (range, 1-6) days. The average postoperative day one VAS was 1.6 (range, 1-3). The average time of union was 20.7 (range, 15-32) weeks. The mean follow-up period was 15.1 (range, 12-24) months. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 7.60 (range, 4.5-13.6) and an average wrist flexion and extension of 69.6° (range, 55-80°) and 57.4° (range, 45-70°). There was no wound infection, neurovascular injury, or other major complication noted. CONCLUSIONS: WALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents. Without a tourniquet, the procedure prevents discomfort caused by tourniquet pain. Without sedation, patients could perform the active range of motion of the injured wrist to check if there is impingement of implants. It eliminates the need of numerous preoperative examinations, postoperative anesthesia recovery room care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.

Comparing morbidities of bone graft harvesting from the anterior iliac crest and proximal tibia: a retrospective study.

BACKGROUND: The anterior iliac crest (AIC) and proximal tibia (PT) are common donor sites for autologous bone graft harvesting. We compared pain levels at these harvest sites on 1 day, 5 days, 2 weeks, 4 weeks, and 8 weeks post-harvest. METHODS: We retrospectively reviewed 18 patients undergoing autologous bone grafting surgery at a level I trauma center between June 2013 and October 2014. Ten grafts were harvested from the AIC group and eight from the PT group. A standard visual analog scale (VAS) was used to rate pain at the harvest sites on postoperative day (POD) 1, 5, 14, 28, and 56 and at the recipient site on POD 1. RESULTS: There were no statistically significant differences between both groups in age (p = 0.474), gender (p = 1.00), incidence of harvest site morbidity (p = 1.00), and average VAS at the recipient site on POD 1 (p = 0.471). VAS at the harvest site on POD 1, 5, and 14 confirmed statistically that pain was more severe in the AIC group than in the PT group (p < 0.001). However, no significant difference was observed on POD 28 and 56 between both groups. Pain was significantly less on POD 1 in the PT group at the harvest site than at the recipient site (p < 0.001). CONCLUSIONS: The PT is a suitable harvest site, producing statistically less pain for at least two postoperative weeks than the AIC. Besides, patients report less postoperative pain at the PT harvest site than at the recipient site.

Drug Repurposing Screening Identifies Tioconazole as an ATG4 Inhibitor that Suppresses Autophagy and Sensitizes Cancer Cells to Chemotherapy.

Background: Tumor cells require proficient autophagy to meet high metabolic demands and resist chemotherapy, which suggests that reducing autophagic flux might be an attractive route for cancer therapy. However, this theory in clinical cancer research remains controversial due to the limited number of drugs that specifically inhibit autophagy-related (ATG) proteins. Methods: We screened FDA-approved drugs using a novel platform that integrates computational docking and simulations as well as biochemical and cellular reporter assays to identify potential drugs that inhibit autophagy-required cysteine proteases of the ATG4 family. The effects of ATG4 inhibitors on autophagy and tumor suppression were examined using cell culture and a tumor xenograft mouse model. Results: Tioconazole was found to inhibit activities of ATG4A and ATG4B with an IC50 of 1.3 µM and 1.8 µM, respectively. Further studies based on docking and molecular dynamics (MD) simulations supported that tioconazole can stably occupy the active site of ATG4 in its open form and transiently interact with the allosteric regulation site in LC3, which explained the experimentally observed obstruction of substrate binding and reduced autophagic flux in cells in the presence of tioconazole. Moreover, tioconazole diminished tumor cell viability and sensitized cancer cells to autophagy-inducing conditions, including starvation and treatment with chemotherapeutic agents. Conclusion: Tioconazole inhibited ATG4 and autophagy to enhance chemotherapeutic drug-induced cytotoxicity in cancer cell culture and tumor xenografts. These results suggest that the antifungal drug tioconazole might be repositioned as an anticancer drug or chemosensitizer.

Ablation of ATG4B Suppressed Autophagy and Activated AMPK for Cell Cycle Arrest in Cancer Cells.

BACKGROUND/AIMS: ATG4B is a cysteine protease required for autophagy, which is a cellular catabolic pathway involved in energy balance. ATG4B expression is elevated during tumor growth in certain types of cancer, suggesting that ATG4B is an attractive target for cancer therapy. However, little is known about the mechanisms through which ATG4B deprivation suppresses the growth of cancer cells. METHODS: Cancer cells were transfected with either siRNA against ATG4B or an expression vector encoding wild-type ATG4BWT or encoding catalytic mutant ATG4BC74A to determine cell cycle progression by propidium iodide staining or by BrdU incorporation assay using flow cytometry. The GFP-MAP1LC3-II puncta and protein levels in the cells were determined by immunofluorescence and immunoblotting, respectively. RESULTS: Knockdown of ATG4B blocked cell proliferation, particularly at the G1-S phase transition, in various cancer cells. Moreover, knockdown of ATG4B or overexpression of the ATG4BC74A catalytic mutant reduced both autophagic flux and ATP levels and increased AMP-activated protein kinase (AMPK) phosphorylation in the cancer cells. Nevertheless, knockdown of ATG4B had only a minor effect on AMPK activation and G1 phase arrest in liver kinase B1 (LKB1)-deficient or AMPK-inhibited cancer cells. CONCLUSION: These results imply that targeting ATG4B might inhibit autophagy and trigger the LKB1-AMPK energy-sensing pathway, resulting in tumor growth suppression.

Lack of Association between Pre-Operative Insulin-Like Growth Factor-1 and the Risk of Post-Operative Delirium in Elderly Chinese Patients.

OBJECTIVE: Postoperative delirium (POD) is a highly prevalent complex neuropsychiatric syndrome in elderly patients. However, its pathophysiology is currently unknown. Early detection and prevention of POD is important; therefore, the aim of this study was to investigate the link between preoperative insulin growth factor 1 (IGF-1) levels in the serum and POD in the Chinese elderly patients. METHODS: One hundred and three patients who were undergoing an orthopedic operation took part in the study. Preoperative serum IGF-1 levels were measured. POD was determined daily using the Confusion Assessment Method (CAM) and DSM-IV TR. Baseline serum IGF-1 levels were compared between patients who did and did not develop POD. Correlation coefficients were calculated to evaluate relationship between baseline characteristics and serum IGF-1 levels. The relationship between baseline biomarkers and delirium status was investigated using logistic regression analysis, adjusting for potential confounding variables. RESULTS: Twenty-three patients developed POD. The POD group had lower MMSE scores and higher CCI scores and proportions of acute admission. Preoperative serum IGF-1 levels were correlated with MMSE scores and age (MMSE: r=0.230, p<0.05; age: r=-0.419, p<0.001). Baseline serum IGF-1 levels did not differ between patients who did and did not develop POD, even after adjusting for potential confounding factors, MMSE score, and age. CONCLUSION: No association was found between preoperative IGF-1 levels and POD, suggesting that they are not direct biomarkers of the incidence of POD among the Chinese elderly population. Further research with larger sample sizes is warranted to clarify the relationship.

Short-Form Mini Nutritional Assessment as a useful method of predicting the development of postoperative delirium in elderly patients undergoing orthopedic surgery.

OBJECTIVE: Postoperative delirium (POD) is a major cause for concern among elderly patients undergoing surgery, often resulting in poor outcome. It is therefore important to predict and prevent POD. The aim of this study was to evaluate the Mini Nutritional Assessment Short-Form (MNA-SF) as a predictor of POD after orthopedic surgery. METHODS: Elderly patients undergoing orthopedic surgery between April 2011 and March 2013 were included in the study (n=544; mean age, 74.24 ± 7.92 years). The MNA-SF was used to evaluate preoperative nutritional status. Delirium was assessed daily after surgery using the confusion assessment method. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria were used to confirm delirium diagnosis. Univariate and multivariate logistic regression analyses were performed to identify key factors associated with POD. RESULTS: POD occurred in 52 patients (9.6%). According to the MNA-SF, 17.5% of subjects were at risk of undernutrition. Adjusting for all potential factors in the final model, age, male gender and lower Mini-Mental State Examination and higher Charlson Comorbidity Index scores were associated with significantly increased likelihood of POD. Subjects who were identified preoperatively as at risk of undernutrition were 2.85 times more likely to develop POD compared to normally nourished subjects (odds ratio: 2.85, 95% confidence interval: 1.19-6.87). CONCLUSIONS: These results suggest that the MNA-SF is a simple and effective tool that can be used to predict incident delirium in elderly patients after orthopedic surgery.

Developing a Prediction Model for Post-Operative Delirium and Long-Term Outcomes Among Older Patients Receiving Elective Orthopedic Surgery: A Prospective Cohort Study in Taiwan.

This study aimed to develop a prediction model for post-operative delirium among older patients receiving elective orthopedic surgery and to evaluate its effectiveness in predicting long-term health outcomes. This prospective cohort study screened all subjects aged over 60 years who were admitted for elective orthopedic surgery in a tertiary medical center in Taiwan from April, 2011, to December, 2013. Demographic characteristics, surgery-related factors, and results of comprehensive geriatric assessment (CGA) were all used to develop the prediction model. Long-term health outcomes, including mortality, nursing home admission, and functional status in the first year after surgery, were used to further evaluate the effectiveness of the prediction model. Overall, 461 patients (median age, 73 years; interquartile range [IQR], 67-80 years; 42.3% males) were enrolled, and 37 patients (8.0%) developed post-operative delirium. Prediction models were developed on the basis of demographic characteristics and surgery-related factors (model 1) and of demographic characteristics, surgery-related factors, and geriatric assessment variables (model 2). Although both models effectively predicted the occurrence of post-operative delirium, duration of post-operative delirium, total hospital days, nursing home admission, and mortality, model 2 was more likely to differentiate cases with functional decline during the first year after surgery. In conclusion, a prediction model developed by using demographic characteristics, surgery-related factors, and results of CGA was highly predictive for post-operative delirium, as well as long-term health and functional outcomes.

Interrelationship of postoperative delirium and cognitive impairment and their impact on the functional status in older patients undergoing orthopaedic surgery: a prospective cohort study.

BACKGROUND: The impact of postoperative delirium on post-discharge functional status of older patients remains unclear, and little is known regarding the interrelationship between cognitive impairment and post-operative delirium. Therefore, the main purpose was to evaluate the post-discharge functional status of patients who experience delirium after undergoing orthopaedic surgery and the interrelationship of postoperative delirium with underlying cognitive impairment. METHOD: This prospective cohort study, conducted at a tertiary care medical center from April 2011 to March 2012, enrolled all subjects aged over 60 years who were admitted for orthopaedic surgery. The baseline characteristics (age, gender, BMI, and living arrangement), surgery-related factors (ASA class, admission type, type of surgery, and length of hospital stay), results of geriatric assessment (postoperative delirium, cognition, depressive mood, comorbidity, pain, malnutrition, polypharmacy, ADL, and instrumental [I]ADL) and 1-12-month postoperative ADL and IADL functional status were collected for analysis. RESULTS: Overall, 9.1% of 232 patients (mean age: 74.7 ± 7.8 years) experienced postoperative delirium, which was significantly associated with IADL decline at only 6 and 12 months postoperatively (RR: 6.22, 95% CI: 1.08-35.70 and RR: 12.54, 95% CI: 1.88-83.71, respectively). Delirium superimposed on cognitive impairment was a significant predictor for poor functional status at 6 and 12 months postoperatively (RR: 12.80, 95% CI: 1.65-99.40 for ADL at the 6th month, and RR: 7.96, 95% CI: 1.35-46.99 at the 12th month; RR: 13.68, 95% CI: 1.94-96.55 for IADL at the 6th month, and RR: 30.61, 95% CI: 2.94-318.54 at the 12th month, respectively). CONCLUSION: Postoperative delirium is predictive of IADL decline in older patients undergoing orthopaedic surgery, and delirium superimposed on cognitive impairment is an independent risk factor for deterioration of ADL and IADL functional status. Early identification of cognitive function and to prevent delirium are needed to improve functional status following orthopaedic surgery.