Frédéric Khiami

Postoperative Admission to a Dedicated Geriatric Unit Decreases Mortality in Elderly Patients with Hip Fracture

Background Elderly patients with hip fracture have a 5 to 8 fold increased risk of death during the months following surgery. We tested the hypothesis that early geriatric management of these patients focused on co-morbidities and rehabilitation improved long term mortality. Methods and Findings In a cohort study over a 6 year period, we compared patients aged >70 years with hip fracture admitted to orthopedic versus geriatric departments in a time series analysis corresponding to the creation of a dedicated geriatric unit. Co-morbidities were assessed using the Cumulative Illness Rating Scale (CIRS). Each cohort was compared to matched cohorts extracted from a national registry (n = 51,275) to validate the observed results. Main outcome measure was 6-month mortality. We included 131 patients in the orthopedic cohort and 203 in the geriatric cohort. Co-morbidities were more frequent in the geriatric cohort (median CIRS: 8 vs 5, P<0.001). In the geriatric cohort, the proportion of patients who never walked again decreased (6% versus 22%, P<0.001). At 6 months, re-admission (14% versus 29%, P = 0.007) and mortality (15% versus 24%, P = 0.04) were decreased. When co-morbidities were taken into account, the risk ratio of death at 6 months was reduced (0·43, 95%CI 0·25 to 0·73, P = 0.002). Using matched cohorts, the average treatment effects on the treated associated to early geriatric management indicated a reduction in hospital mortality (−63%; 95% CI: −92% to −6%, P = 0.006). Conclusions Early admission to a dedicated geriatric unit improved 6-month mortality and morbidity in elderly patients with hip fracture.

Accuracy of the preoperative planning for cementless total hip arthroplasty. A randomised comparison between three-dimensional computerised planning and conventional templating.

INTRODUCTION A high accuracy was recently reported for the three-dimensional (3D) computerised planning of total hip arthroplasty (THA), comparing well with navigation regarding leg length and femoral offset. However, there is no randomised study comparing 3D preoperative planning with conventional 2D templating in terms of accuracy and clinical relevance. HYPOTHESIS The 3D preoperative planning has a higher accuracy than the conventional 2D preoperative templating regarding the implants size and their positioning. PATIENTS AND METHODS A prospective comparative randomised study was carried out from 2008 to 2009, including two groups of 30 patients who underwent THA for primary osteoarthritis. One surgeon performed all the surgical procedures using a minimally invasive direct anterior approach. In one group, the planning was made on calibrated X-rays using 2D templates. In the other group, a CT-scan based 3D computerised planning was performed with dedicated software. The reconstructed hip final anatomy was compared postoperatively to the preoperative planning and the accuracy was expressed as the mean difference (±SD) between the planned positioning and the final positioning of the implants. RESULTS The prediction rate for the stem and the cup sizes were respectively of 100% and 96% in the 3D group versus 43% for both components in the 2D group. When combining both components, the prediction rate was 96% in the 3D group versus 16% in the 2D group. In the 3D group, a high accuracy was achieved for the planning of the leg length (-1.8±3.6 mm ranging from -8 to+4mm) and the femoral offset (-0.07±2.7 mm ranging from -5 to+4mm) versus 1.37±6.4mm ranging from -9 to 13 mm and 0.33±5.7 mm (-16 to 11 mm) in the 2D templating group (P<0.0001). DISCUSSION The 3D planning gives a higher accuracy than conventional 2D templating in forecasting the size of cup and the stem. This contributes to the prediction for leg length and offset that is more reliable with the 3D technique. This study suggests that 3D planning CT-scan data is an attractive alternative to navigation to restore these parameters. The high accuracy achieved by a low-experience surgeon suggests that 3D planning may help shorten the learning curve when using the minimally invasive direct anterior approach. LEVEL OF EVIDENCE Level III low-powered prospective randomized trial.

Perioperative management of elderly patients with hip fracture.

1336 December 2014 W ORLDWIDE 1.6 million patients suffer from hip fracture every year, and this number has increased by 25% every decade as the population continues to grow.1 Nevertheless, a decrease in hip fracture rate has been recently observed, particularly in women (up to −24% in women older than 85 yr), owing to several factors including awareness about osteoporosis and the danger of falls.2 Hip fracture has devastating consequences in the elderly patients and thus is associated with a poor outcome. This contrasts markedly with the relatively simple surgical procedures needed for treatment. One third of elderly patients with hip fracture are dead 1 yr later and, in surviving patients, hip fractures have a negative effect on daily life activities and quality of life.1–3 The elderly patients with hip fracture remain a medical challenge for the anesthesiologist, mainly because of the frequent and numerous comorbidities encountered; moreover, the incidence of these comorbidities has increased during the past years.2 Many improvements have been introduced in the care of these patients, including improved surgical devices, earlier mobilization, prophylactic administration of antibiotics and anticoagulant, as well as increased rate of admission into rehabilitation unit. Nevertheless, the mortality rate has plateaued since 1998.2 Given the magnitude of the problem, some effective strategies have been recently proposed to prevent mortality after hip fracture.3,4 This Clinical Concept and Commentary summarizes these strategies and explain the future directions for research, but focuses on specific issues related to hip fracture and not to more general aspect related to anesthesia in elderly patients.5 Morbidity and Mortality After hip fracture, in-hospital mortality ranges from 2.3 to 13.9%, but the risk persists beyond the immediate surgical period with 6-month mortality rates ranging from 12 to 23%.3 The mortality risk increases within 6 months and thereafter decreases, and is higher in men. When compared to elective hip replacements, patients presenting with hip fracture have a 6to 15-fold mortality risk.6 This difference is explained by the high prevalence of preexisting medical conditions in this population: 75% of patients are older than 70 yr,1 and 95% of patients present with at least one major preoperative comorbidity (fig. 1).7 Three in four hip fracture-associated deaths may be causally related to preexisting medical conditions rather than the fracture itself.8 This indicates that the hip fracture destabilizes a frail elderly population with a high burden of preexisting morbidities, thereby resulting in excess mortality. Some new acute conditions (stroke and cardiac events) may have also provoked falling and thus hip fracture. Frailty should be understood as a vulnerability and a decline of physiologic age-related functional capacities to confront an acute stress such as hip fracture. To summarize, it can be considered in the presence of at least one of the following conditions: (1) advanced age, the “oldest old” (i.e., >90 yr); (2) presence of several comorbidities; and (3) new acute medical conditions. Any of these conditions can weaken elderly patients with hip fracture.

Iliac crest bone graft harvesting complications: A case of liver herniation

The iliac crest is an easily accessible donor site offering a relatively large and safe supply of bone. There are however possible complications; residual pain frequently, and more rarely herniation. This latters true incidence is unknown in a literature review, which found 15 articles. We report a case of liver herniation in a 64-year-old overweight lady after harvesting bone from her iliac crest. The clinical diagnosis was confirmed by CT scan. Despite an appropriate surgical repair, the hernia recurred. This serious complication of bone harvesting from the iliac crest, and possible other undesirable events described, prompted reconsideration of our harvesting techniques, and the use in our unit of bone substitutes or cell therapy to fill bone defects.

Endplate denervation correlates with Nogo-A muscle expression in amyotrophic lateral sclerosis patients.

Data from mouse models of amyotrophic lateral sclerosis (ALS) suggest early morphological changes in neuromuscular junctions (NMJs), with loss of nerve–muscle contact. Overexpression of the neurite outgrowth inhibitor Nogo‐A in muscle may play a role in this loss of endplate innervation.

Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique

Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergone a number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger. Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimally invasive harvesting through two lateral proximal and distal approaches considerably reduces cosmetic problems. The femoral tunnel is made from the outside to the inside using a specific targeting device, and the transplant harvest site is closed using the Jaeger procedure so as not to weaken lateral knee stabilizing structures. This procedure consists in opening the lateral intermuscular septum 1cm from the femur to let it shift laterally and allow the transplant harvesting area to be closed. This technique uses a fascia lata transplant, the harvesting of which has shown few iatrogenous complications but requires rigorous adherence to certain rules.

Management of recent first-time anterior shoulder dislocations.

The management of a first episode of anterior shoulder dislocation starts with an analysis of the causative mechanism and a physical examination to establish the diagnosis. Based on the findings, the case can be classified as simple or accompanied with complications, most notably vascular or nerve injuries. Two radiographs perpendicular to each other should be obtained to confirm the diagnosis then repeated after the reduction manoeuvres. Additional imaging studies may be needed to assess concomitant bony lesions (impaction lesions or fractures). External reduction should always be attempted after premedication appropriate for the severity of the pain. General anaesthesia may be necessary. There is no consensus regarding the optimal reduction technique, although the need for gentle manoeuvres that do not cause pain is universally recognised. Immobilisation currently involves keeping the elbow by the side with the arm internally rotated for 3-6weeks depending on patient age. Vessel and nerve injuries are rare but can cause major functional impairments. Follow-up evaluations are in order to check the recovery of normal function, which may be more difficult to achieve in patients with concomitant lesions; and to detect recurrent shoulder instability and rotator cuff lesions. At the acute phase, surgery is indicated only in patients with complications or after failure of the reduction manoeuvres. Shoulder immobilisation with the arm externally rotated and surgical treatment of the first episode are controversial strategies that are discussed herein.

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture

Abstract Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture. In this cohort study, all patients admitted between 2009 and 2013 in our dedicated geriatric postoperative unit after hip fracture surgery with a cardiac troponin I determination were included and divided into Control, ITR, and acute coronary syndrome (ACS) groups. The primary end point was a composite criteria defined as 6-month mortality and/or re-hospitalization. Secondary end points included 30-day mortality, 6-month mortality, and 6-month functional outcome. Three hundred twelve patients were (age 85 ± 7 years) divided into Control (n = 217), ITR (n = 50), and ACS (n = 45) groups. There was no significant difference for any postoperative complications between ITR and Control groups. In contrast, atrial fibrillation, acute heart failure, hemorrhage, and ICU admission were significantly more frequent in the ACS group. Compared to the Control group, 6-month mortality and/or rehospitalization was not significantly modified in the ITR group (26% vs. 28%, P = 0.84, 95% confidence interval [CI] of the difference -13%–14%), whereas it was increased in the ACS group (44% vs. 28%, P = 0.02, 95% CI of the difference 2%–32%). ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group. In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

Association between Cognitive Status before Surgery and Outcomes in Elderly Patients with Hip Fracture in a Dedicated Orthogeriatric Care Pathway

BACKGROUND Dementia is associated with a worse prognosis of hip fracture, but the impact of a dedicated geriatric care pathway on the prognosis of these patients has not been evaluated. OBJECTIVE According to the cognitive status before surgery, our main objective was to compare mortality rate at 6 months; secondary outcomes were to compare in-hospital complications, the risk of new institutionalization, and the ability to walk at 6 months. METHODS Between 2009 and 2015, all patients (>70 years) admitted after hip fracture surgery into a dedicated unit of peri-operative geriatric care were included: patients with dementia (DP), without dementia (NDP), and with cognitive status not determined (CSND). Data are expressed as hazard ratio (HR) for multivariate cox analysis or odds ratio (OR) for multivariate logistic regression analysis and their 95% confidence interval (CI). RESULTS We included 650 patients (86±6 years): 168 DP, 400 NDP, and 82 CSND. After adjustment for age, sex, comorbidities, polypharmacy, pre-fracture autonomy, time-to-surgery, and delirium, there were no significant differences for 6-month mortality (DP versus NDP: HR = 0.7[0.4-1.2], DP versus CSND: HR = 0.6[0.3-1.4], CSND versus NDP: HR = 0.8[0.4-1.7]); but DP and CSND were more likely to be newly institutionalized after 6 months compared to NDP (OR DP = 2.6[1.4-4.9], p = 0.003, OR CSND = 2.9[1.4-6.1], p = 0.004). 92% of population was walking after 6 months (63% with assistance): no difference was found between the three groups. CONCLUSION In a dedicated geriatric care pathway, DP and CSND undergoing hip surgery have the same 6-month mortality and walking ability as NDP.

Compression stockings in ankle sprain: a multicenter randomized study

OBJECTIVES Ankle sprain is a frequently encountered traumatic injury in emergency departments and is associated with important health expenses. However, the appropriate care of this traumatic injury remains a matter of debate. We tested the hypothesis that compression stockings speed up recovery from ankle sprain. METHODS Recent (<48 hours) cases of ankle sprain without other traumatic injury in patients aged between 18 and 55 years were included. Patients were randomly allocated to placebo Jersey or class II compression stockings (Venoflex; Thuasne, Levallois-Perret, France). The primary end point was the time to recovery of normal painless walking without requirement for analgesic drug. Secondary end points were time to return to sport activity, pain, analgesic consumption, and ankle edema (bimalleolar and midfoot circumferences). RESULTS We randomized 126 patients and analyzed 117 patients (60 in the placebo group and 57 in the compression group). The median time to normal painless walking was not significantly decreased (P = .16). No significant differences were observed in pain, analgesic consumption, and bimalleloar and midfoot circumferences. No safety issue was reported. In the subgroup of patients with regular sport activity, the time to return to sport activity was shorter in patients treated with compression stockings (P = .02). CONCLUSIONS Compression stockings failed to significantly modify the time to return to normal painless walking in ankle sprain. A beneficial effect was observed only in a subgroup of patients, as compression stockings significantly decreased the time to return to sport activity.