Edward T. Su

The effects of nutritional status on outcome after hip fracture.

OBJECTIVE To determine the effect of nutrition on patient outcome after hip fracture. STUDY DESIGN Retrospective review of prospectively collected data. METHODS Four hundred ninety hip fracture patients had albumin and total lymphocyte count levels determined at the time of admission and constituted the study population. These variables were examined as predictors for outcomes, including: in-hospital mortality, postoperative complications, hospital length of stay, hospital discharge status, one-year mortality rate, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery. RESULTS Eighty-seven patients (18 percent) were found to be malnourished on hospital admission based on a preoperative albumin level of < 3.5 grams/deciliter, and 280 patients (57 percent) based on a total lymphocyte count of < 1,500 cells/milliliter. An albumin level of < 3.5 grams/deciliter was predictive for increased length of stay (p = 0.03) and for in-hospital mortality (p = 0.03). A total lymphocyte count < 1,500 cells/milliliter was predictive for one-year mortality (p < 0.01). Patients with abnormal albumin and total lymphocyte count were 2.9 times more likely to have a length of stay greater than two weeks (p = 0.03), 3.9 times more likely to die within one year after surgery (p = 0.02), and 4.6 times less likely to recover their prefracture level of independence in basic activities of daily living (p < 0.01). Neither parameter was predictive for patients developing a postoperative complication, hospital discharge status (home versus nursing home), recovery of prefracture ambulatory ability, or independence in instrumental activities of daily living at twelve-month follow-up. CONCLUSION Patients at risk for poor outcomes after hip fracture can be identified using relatively inexpensive laboratory tests such as albumin and total lymphocyte count.

Periprosthetic Femoral Fractures Above Total Knee Replacements

Abstract Periprosthetic femoral fractures above total knee replacements can be managed by a variety of methods, including casting, open reduction and internal fixation, external fixation, or revision arthroplasty. Because no single method has emerged as the optimal choice for all such fractures, it is important to understand which options are appropriate for each fracture pattern. Early classification systems focused on displacement as a major indication for either surgical or nonsurgical management. However, recent techniques and current implants have made surgical management preferable for most periprosthetic fractures. Classification based on fracture location can help guide such treatment. Generally, intramedullary nails are best for proximal fractures, fixed‐angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening.

Does blood transfusion increase the risk of infection after hip fracture

OBJECTIVE To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection. STUDY DESIGN Prospective, consecutive. METHODS Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics. RESULTS Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant. CONCLUSIONS Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused.

Effect of Acute Inpatient Rehabilitation on Outcome after Fracture of the Femoral Neck or Intertrochanteric Fracture

A study was performed to assess the impact of intensive inpatient rehabilitation on the outcome after a fracture of the femoral neck or an intertrochanteric fracture. Before 1990, our hospital did not have an inpatient rehabilitation program. On January 1, 1990, a diagnosis-related-group-exempt (DRG-exempt) acute rehabilitation program was initiated. Patients were discharged to this program after evaluation by a staff physiatrist. Before 1990, twenty-seven (9.0 per cent) of 301 patients were discharged to an outside rehabilitation facility. After January 1990, the percentage of patients who were discharged to the DRG-exempt program increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993; this difference was significant (p < 0.01). Before 1990, the average duration of the stay in the hospital was 21.9 days. After January 1990, the average duration for the patients who did not enter the rehabilitation program was 20.0 days whereas the average duration for those who did was 31.4 days (16.1 days for acute care and 15.6 days for the rehabilitation program). There were no differences in the hospital discharge status or in the walking ability, place of residence, need for home assistance, or independence in basic and instrumental activities of daily living at the six and twelve-month follow-up examinations between patients who had been managed before initiation of the rehabilitation program and those managed after it or between patients who had been discharged to this program after its initiation and those who had not. These results raise serious questions regarding the global cost-effectiveness of these programs for patients who have had a fracture of the femoral neck or an intertrochanteric fracture.

The effect of an attachable lateral support plate on the stability of intertrochanteric fracture fixation with a sliding hip screw.

BACKGROUND Use of a sliding hip screw (SHS) alone for some unstable intertrochanteric femur fractures can allow excessive medial shaft displacement during impaction. This study evaluated the effect of an attachable lateral support plate on these fractures after loading. METHODS Unstable, three-part intertrochanteric fractures were created in 10 matched pairs of embalmed femurs that were instrumented with 135-degree SHSs with or without an attachable lateral support plate. Under physiologic loading, inferior and lateral head displacements and lag screw sliding distances were measured. RESULTS After 10,000 cycles at 750 N, all measurements for femurs with the lateral support plate were significantly less than for the femurs with the SHS alone: mean lateral difference was 1.7 mm (34%) (p < 0.05), mean inferior difference was 3.0 mm (38%) (p < 0.05), and mean lag screw sliding difference was 4.5 mm (58%) (p < 0.05). CONCLUSION The addition of an attachable lateral support plate to an SHS significantly decreased displacement of the femoral head after cyclic loading.

Semiconstrained knee arthroplasty in the setting of a chronic knee dislocation: a case report.

We present the case of a 27-month chronic knee dislocation treated with a semiconstrained, stemmed total knee arthroplasty. The patient was neurovascularly intact preoperatively but had severe functional limitations caused by pain, stiffness, and instability. At 2-year follow-up, the patient remains pain-free with functional range of motion and the ability to ambulate without complication. This case report represents the longest-cited chronic knee dislocation treated with a reconstructive procedure.