Deuk Soo Hwang

Early Assessment of Delirium in Elderly Patients after Hip Surgery

Objective This study is intended to identify predictive factors of delirium, including risk factors and prodromal symptoms. Methods This study included sixty-five patients aged 65 years or older who had undergone hip surgery. Baseline assessments included age; gender; admission type (acute/elective); reason for surgery (fracture/replacement); C-reactive protein (CRP); Acute Physiology, Age, Chronic Health Evaluation (APACHE III); and the Mini-Mental State Examination (MMSE). The Korean version of the Delirium Rating Scale-Revised-98 (K-DRS-98) was used to assess prodromal symptoms daily before the onset of delirium. Results Almost 28% (n=18) of the 65 patients developed delirium after surgery. Delirium in elderly patients after hip surgery was observed more often in older patients and those with acute admission, hip fracture, higher APACHE III score, lower MMSE score, and higher CRP levels within early days after the operation. Sleep-wake cycle disturbances, thought process abnormalities, orientation, and long-term memory in symptom items of K-DRS-98 were showed significant difference on 4 days before delirium, lability of affect on 3 days before, perceptual disturbances and hallucination, and visuo-spatial ability on 2 days before, and delusion, motor agitation, and short-term memory on the day before the occurrence of delirium. CRP levels within 24 hours and 72 hours after hospitalization were significantly higher in the delirium group. Conclusion Medical professionals must pay attention to behavioral, cognitive changes and risk factors in elderly patients undergoing hip surgery and to the prodromal phase of delirium. K-DRS-98 may help in identifying the prodromal symptoms of delirium in elderly patients after hip surgery.

Post-traumatic cerebral fat embolism prior to operative repair of femoral and tibial fractures.

Rare cases of primary cerebral fat embolism as a postoperative complication have been reported. In addition, cerebral fat embolism occurring before operative repair without shunt lesion are more rarely reported. We report a patient with a posttraumatic cerebral fat embolism resulting in severe neurologic dysfunction without right to left shunt. A 25-year-old man was brought to the hospital immediately after a traffic accident. He sustained a right segmental femoral shaft fracture and a left tibial shaft fracture. The patient was alert with no neurological deficits. Approximately 13 hours after injury, the patient developed acute mental status deterioration and dyspnea. Magnetic resonance imaging of the brain revealed extensive multifocal infarction owing to embolic showering throughout nearly the entire brain parenchyma. Computed tomography with intravenous contrast revealed no evidence of embolism in the lung, abdomen, and pelvis. Transthoracic and transesophageal echocardiogram revealed no circulating embolic particles or intracardiac shunt. The patient underwent closed reduction and internal fixation with a reamed intramedullary nail in the tibia and underwent open reduction and internal fixation with a reamed nail in the femur at 5 days after injury. We performed decompression of a hematoma containing a large number of lipid droplets via a small incision in the femur shaft fracture, established suction drainage of the tibia medullar cavity, and applied a tourniquet to the thigh in the tibia shaft fracture. Supportive medical treatment included endotracheal ventilatory support and tracheostomy. The patient was discharged from the hospital 50 days after admission. On follow-up 2 months later, he had returned to activities of daily living, however a speech disturbance remained.

Usefulness of Arthroscopic Treatment of Painful Hip after Acetabular Fracture or Hip Dislocation

Background Painful hip following hip dislocation or acetabular fracture can be an important signal for early degeneration and progression to osteoarthritis due to intraarticular pathology. However, there is limited literature discussing the use of arthroscopy for the treatment of painful hip. The purpose of this retrospective study was to analyze the effectiveness and benefit of arthroscopic treatment for patients with a painful hip after major trauma. Methods From July 2003 to February 2013, we reviewed 13 patients who underwent arthroscopic treatment after acetabular fracture or hip dislocation and were followed up for a minimum of 2 postoperative years. The degree of osteoarthritis based on the Tonnis classification pre- and postoperatively at final follow-up was determined. Clinical outcomes were evaluated using visual analogue scale for pain (VAS) and modified Harris hip score (MHHS), and range of motion (ROM) of the hip pre- and postoperatively at final follow-up. Results There were nine male and four female patients with a mean age at surgery of 28 years (range, 20 to 50 years). The mean follow-up period of the patients was 59.8 months (range, 24 to 115 months), and the mean interval between initial trauma and arthroscopic treatment was 40.8 months (range, 1 to 144 months). At the final follow-up, VAS and MHHS improved significantly from 6.3 and 53.4 to 3.0 and 88.3, respectively (p = 0.002 and p < 0.001, respectively). However, there were no significant differences in hip flexion, abduction, adduction, external rotation, and internal rotation as minor improvements from 113.1°, 38.5°, 28.5°, 36.5°, and 22.7° to 118.5°, 39.0°, 29.2°, 38.9°, and 26.5° were observed, respectively (p = 0.070, p = 0.414, p = 0.317, p = 0.084, and p = 0.136, respectively). None of the patients exhibited progression of osteoarthritis of the hip at the final follow-up. Conclusions Arthroscopic treatment after acetabular fracture or hip dislocation is effective and delays the progression of traumatic osteoarthritis.

Tibial Unreamed Intramedullary Nailing Using Schanz Screws in Displaced Diaphyseal Segmental Fractures

Reduction and manipulation using percutaneously fixated Schanz screws and unreamed intramedullary nailing facilitates fracture reduction, promotes early weight bearing, and decreases complications such as nonunion, malalignment, in failure.

Distal hybrid interlocking in the femoral shaft fracture

This technique may be beneficial for stabilizing fractures less invasively and may decrease complications, such as nonunion and postoperative infection, by avoiding iatrogenic devascularization of the fracture site.

Extended Sinus Tarsi Approach for Treatment of Displaced Intraarticular Calcaneal Fractures Compared to Extended Lateral Approach

Background: We compared the radiographic results and clinical outcomes of patients operated on via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA) for treatment of displaced intraarticular calcaneal fractures. Methods: We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated on between January 2009 and March 2015. We evaluated pre- and postoperative x-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, satisfaction, and postoperative complications were investigated at the 3-year follow-up. Results: Neither the postoperative nor 3-year follow-up Böhler angles, nor the calcaneal width, differed significantly between the 2 groups (both P > .05). However, the maximum step-off of the posterior facet on the 3-month CT follow-up of the ESTA group was significantly less than that of the ELA group (P < .05). We found no significant between-group differences in terms of postoperative translation (P = .232) or angulation (P = .132) of the sustentacular fragment on the 3-month CT follow-up. At the 3-year follow-up, we found no significant between-group difference in the mean visual analog scale pain score at rest (P = .641) or during weightbearing (P = .525). We found no significant between-group difference in the Foot Function Index (FFI) (P = .712) or self-reported satisfaction (P = .823). The ELA group experienced significantly more wound complications (P = .041) and nonunions (P = .041) than the ESTA group. Four instances of superficial peroneal nerve injury were reported in the ESTA group (P = .127). Conclusion: Compared with the ELA, the ESTA afforded comparable, favorable radiological results and clinical outcomes, associated with fewer wound complications and nonunions. We suggest that the ESTA is an effective operative option when treating displaced, intraarticular calcaneal fractures. Level of Evidence: Level III, comparative study.

Comparison of Radiographic and Clinical Results After Extended Distal Chevron Osteotomy With Distal Soft Tissue Release With Moderate Versus Severe Hallux Valgus

Background: We compared the radiographic and clinical outcomes of moderate and severe hallux valgus treated by extended distal chevron osteotomy (EDCO) and distal soft tissue release (DSTR). Methods: We performed a retrospective analysis comparing the utility of EDCO for the treatment of moderate (36 patients, 46 feet) and severe (36 patients, 42 feet) hallux valgus. The radiologic outcomes were evaluated based on the preoperative and 3-year follow-up x-rays. The clinical results were investigated based on the 3-year follow-up Manchester-Oxford Foot Questionnaire (MOXFQ), patient satisfaction, and postoperative complications. Results: The mean postoperative intermetatarsal angle, hallux valgus angle, tibial sesamoid position, and relative metatarsal bone length were significantly different compared with the preoperative values for both the moderate and severe groups (P < .001). At 3-year follow-up, intergroup differences were observed in the mean postoperative intermetatarsal angle (P = .001), hallux valgus angle (P = .003), and tibial sesamoid position (P = .013); however, mean radiographic results were within the normal range for both groups. There were no intergroup differences for either the first metatarsal bone length (P = .172) or shortening (P = .621). No significant difference in MOXFQ (P = .525) was evident between the groups at 3-year follow-up. In satisfaction analysis, 82.6% of the moderate group reported good to excellent results, as did 81.0% of the severe group (P = .815). A total of 7 complications were reported in each group (P = 1.000). Conclusion: The present study showed that midterm mean radiographic results of both moderate and severe hallux valgus treated by EDCO with DSTR were favorable, and those values were within the normal range. Clinical outcomes were comparable between the 2 groups, including overall efficacy. Based on these results, we recommend EDCO with DSTR as an efficient and reliable operative option for both moderate and severe hallux valgus. Level of Evidence: Level III, retrospective comparative study.

Radiological and Clinical Effectiveness of a Novel Calcaneal Fracture Brace after Intra-articular Calcaneal Fracture Surgery

Background After calcaneal fracture surgery, a short leg splint and cast are typically applied. However, these restrict joint exercises, which is inconvenient for patients. In addition, there is a risk of complications, such as pressure ulcers or nerve paralysis with a short leg cast. In this study, we evaluated clinical and radiological outcomes of the use of a specially designed calcaneal brace after calcaneal fracture surgery. Methods From among patients who underwent open reduction and internal fixation for calcaneal fracture between July 9, 2013 and May 31, 2017, 102 patients who wore a calcaneal fracture brace (group A) and 82 patients who wore a postoperative short leg cast (group B) were randomly chosen for this study. Radiological changes and clinical factors were compared between the two groups. After swelling at the surgical site decreased, a special calcaneal brace was applied to patients in group A. They were allowed to perform early weight bearing and joint motion. Patients in group B were immobilized in a short leg cast and were told to avoid weight bearing for 6 weeks. In each group, the Böhlers angle and Gissanes angle were measured and compared using postoperative and final follow-up radiographs. Pain (measured using a visual analogue scale [VAS]) and ankle joint range of motion (dorsiflexion, plantar flexion, eversion, and inversion) were measured serially until the final follow-up visit. Results There were no significant differences in the Böhlers angle or Gissanes angle between the two groups as measured postoperatively and at the final follow-up (paired t-test). Differences in the VAS pain score and eversion were also statistically nonsignificant between the two groups. However, group A had a significantly higher range of dorsiflexion (p = 0.021), plantar flexion (p = 0.012), and inversion (p = 0.045) of the ankle than group B (independent t-test). Conclusions Application of the calcaneal fracture brace after open reduction and internal fixation of a calcaneal fracture not only maintained the fracture reduction but allowed for greater joint motion than the short leg cast. Thus, the calcaneal fracture brace can be considered an effective postoperative management option that enables early resumption of daily activities and facilitates postoperative joint motion.

The value of axial loading three dimensional (3D) CT as a substitute for full weightbearing (standing) 3D CT: Comparison of reproducibility according to degree of load

BACKGROUND Full weightbearing (WB) three dimensional computed tomography (3D CT) is an excellent imaging tool. However, due to its high cost, it is only used in a few hospitals. We evaluated the usefulness and cost-effectiveness of axial loading (AL) 3D CT by comparing bony alignments with standing radiographs, and assessed reproducibility according to the degree of AL. METHODS Eighty patients (156 feet), who underwent standing radiographs and 3D CT with an AL device from January 2016 to May 2017, were investigated. According to the degree of AL (AL force×100/body weight), the patients were randomly assigned to three groups: Group A (30-50%; n=21, 40 feet), Group B (50-70%; n=32, 63 feet), and Group C (70-100%; n=27, 53 feet). The following angles were measured three times by two orthopedists: hallux valgus (HVA), 1st-2nd intermetatarsal (IMA1-2), and talo-navicular coverage (TNCA), calcaneal pitch (CPA), talo-1st metatarsal (T1MA), and talo-calcaneal angle (TCA). Agreements between the two imaging methods were analyzed and compared according to the degree of axial loading in each group. RESULTS Intra- and interobserver reliability was excellent (>0.75). In Group A (30-50% AL), all of the angles except HVA and IMA1-2 differed (p<.05). In Group B (50-70%), TNCA (p=.023), T1MA (p=.017), and TCA (p=.035) differed. In Group C (70-100%), none of the angles differed between the two imaging methods (p>.05). Higher agreement between the two imaging methods was realized when 70% or more(>70%) AL was applied. CONCLUSIONS AL 3D CT with >70% axial load has full WB effects and can be substituted for expensive full WB 3D CT.

Arthroscopic Bankart Repair and Rotator Interval Plication by Transglenoid Technique: Preliminary Report

Purpose: To evaluate the clinical results of arthroscopic Bankart repair and rotator interval plication by the transglenoid technique on Traumatic Unidirectional Bankart Surgery (TUBS) with concomitant rotator interval widening. Materials and Methods: From May 2002 to May 2003, 13 cases who underwent arthroscopic Bankart repair and rotator interval plication by the transglenoid technique were studied, out of the 14 cases that were diagnosed as TUBS with concomitant rotator interval widening. Follow up period was at least 1 year. Results were evaluated by Rowe score before and after surgery. Results: All the cases were male. Nine cases were on the right shoulder and 4 on the left. The mean age was 22 years old (range, 14-26 years old). The mean duration from injury to operation was 4.3 (range, 1.3-10) years. The Rowe score was improved from 58.3 to 86.4 (p=0.00). Overall outcomes were excellent in 10 cases, good in 2 and fair in 1 at final follow up. There was no sulcus sign in any of the cases at the last follow up, and redis location did not appear in any of the cases during the follow up period. Conclusion: In the treatment of TUBS with concomitant rotator interval widening, arthroscopic Bankart repair and rotator interval plication by the transglenoid technique have made good results.