Giovanni Zatti

Duration of Postoperative Delirium Is an Independent Predictor of 6‐Month Mortality in Older Adults After Hip Fracture

To evaluate the association between number of days with delirium and 6‐month mortality in elderly adults after hip fracture surgery.

The Combined Effect of ADL Impairment and Delay in Time from Fracture to Surgery on 12-Month Mortality: An Observational Study in Orthogeriatric Patients

BACKGROUNDnDelayed surgery (ie, >48 hours from arrival in hospital) and pre-fracture disability are thought to be long-term risk factors for mortality in patients with hip fracture (HF). However, the combined effect on mortality of these two conditions has not been satisfactorily assessed in previous studies.nnnOBJECTIVEnTo assess the combined effect of pre-fracture disability and delayed surgery on 12-month mortality in a population of elderly patients after HF surgical treatment.nnnDESIGNnRetrospective cohort study with 12-month follow-up.nnnSETTINGnAn orthogeriatric unit (OGU) in a university hospital in Italy.nnnMETHODSnAll patients (nxa0= 390) admitted to an OGU from March 2007 to December 2010 who underwent proximal HF surgery and who were not transferred to other hospitals were considered for the analyses. Pre-fracture disability was defined as having an impairment in more than one activity of daily living (ADL). The 12-month mortality was assessed by a Kaplan-Meyer analysis and by a Cox proportional hazards regression models adjusting for relevant potential confounders.nnnRESULTSnAfter adjusting for potential confounders, patients with both delayed surgery and pre-fracture disability had a significantly higher 12-month mortality (hazard ratio [HR]xa0= 5.80; 95% confidence interval [CI]xa0= 2.11-15.92) than patients with neither delayed surgery nor disability (reference group). Patients with disability but not delayed surgery had a nearly 4-fold increased mortality risk (HR, 3.98; 95% CI 1.41-11.27) than patients in the reference group.nnnCONCLUSIONSnPatients with both pre-fracture disability and delayed HF surgical treatment had a nearly six-fold increased 12-month mortality risk than did patients with neither disability nor delayed surgery.

A comparison between two co-managed geriatric programmes for hip fractured elderly patients

Background and aims: Hip fracture in older people is an event associated with a high incidence of morbidity and mortality. In this study we compared the clinical outcomes of two groups of orthogeriatric patients in an orthogeriatric care (OC) programme. The OC course, developed into the GeriatricWard, starts from the Emergency Department (OC-1, n=174) or from the Orthopaedic Department after surgery (OC-2, n=87). Methods: For this purpose, OC patients were prospectively enrolled from March 2007 to June 2009, following OC criteria. Door-to-bed time, time to surgery, mobilisation time, length of stay, and post-operative complications were compared between the OC groups. Results: OC-1 patients differ from OC-2 ones only for residence at admission (14.4% vs 4.6% lived in nursing homes, p=0.02). Concerning outcomes, in the OC-1 group only mobilization time was significantly lower (p=0.01). No differences were observed in post-operative complications. Conclusions: In frail older people, hip fracture co-management, with the geriatrician as primary attendant, leads to satisfying outcomes. The OC-1 and OC-2 courses exhibit similar clinical results. An improvement in several organisational aspects, including coordination between hospital and rehabilitation services, is warranted.

Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients

BackgroundAge is one of the most robust risk factors for hip fracture. Recent projections indicate that almost half of hip fractures are occurring with an increasing trend among the “oldest old” (i.e., in those aged >85xa0years).AimsTo compare clinical characteristics, outcomes, and risk factors for 6-month mortality in two groups of “oldest old” patients (group 1xa0=xa085–89, group 2xa0>xa090xa0years), after hip fracture surgery.MethodsObservational prospective cohort study with 6-month follow-up, performed in an Orthogeriatric Unit of an academic hospital between March 2007 and November 2012.ResultsTwo hundred seventy-five patients (group 1: Nxa0=xa0171; group 2: Nxa0=xa0104) underwent a comprehensive geriatric assessment, including demographics, clinical, functional, nutritional, and mental status. The 6-month rehospitalization and mortality rates after surgery were assessed through structured telephone interviews with patient’s caregivers. Multivariate logistic regression models were used to evaluate predictors of 6-month mortality, adjusting for relevant covariates. Fifty-eight patients died at follow-up. The in-hospital and 6-month mortality rates were significantly higher for patients of group 2 than for those of group 1. After adjusting for covariates, the multivariate logistic regressions showed that severe disability (OR 2.24, 95xa0% CI 1.08–4.65) and postoperative delirium (POD) (OR 3.80, 95xa0% CI 1.72–8.39) were predictors of 6-month mortality.ConclusionsPatients aged >90xa0years who underwent hip fracture surgery are more likely to die at 6xa0months than those aged 85–89xa0years. Pre-fracture disability and POD are predictors of this excess of mortality.

Sports hernia and femoroacetabular impingement in athletes: A systematic review

AIMnTo investigate the association between sports hernias and femoroacetabular impingement (FAI) in athletes.nnnMETHODSnPubMed, MEDLINE, CINAHL, Embase, Cochrane Controlled Trials Register, and Google Scholar databases were electronically searched for articles relating to sports hernia, athletic pubalgia, groin pain, long-standing adductor-related groin pain, Gilmore groin, adductor pain syndrome, and FAI. The initial search identified 196 studies, of which only articles reporting on the association of sports hernia and FAI or laparoscopic treatment of sports hernia were selected for systematic review. Finally, 24 studies were reviewed to evaluate the prevalence of FAI in cases of sports hernia and examine treatment outcomes and evidence for a common underlying pathogenic mechanism.nnnRESULTSnFAI has been reported in as few as 12% to as high as 94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain. Cam-type impingement is proposed to lead to increased symphyseal motion with overload on the surrounding extra-articular structures and muscle, which can result in the development of sports hernia and athletic pubalgia. Laparoscopic repair of sports hernias, via either the transabdominal preperitoneal or extraperitoneal approach, has a high success rate and earlier recovery of full sports activity compared to open surgery or conservative treatment. For patients with FAI and sports hernia, the surgical management of both pathologies is more effective than sports pubalgia treatment or hip arthroscopy alone (89% vs 33% of cases). As sports hernias and FAI are typically treated by general and orthopedic surgeons, respectively, a multidisciplinary approach for diagnosis and treatment is recommended for optimal treatment of patients with these injuries.nnnCONCLUSIONnThe restriction in range of motion due to FAI likely contributes to sports hernias; therefore, surgical treatment of both pathologies represents an optimal therapy.

Task-oriented exercises and early full weight-bearing contribute to improving disability after total hip replacement: a randomized controlled trial

Objective: To evaluate the efficacy of an in-hospital programme based on task-oriented exercises associated with early full weight-bearing in patients with multiple comorbidities undergoing total hip replacement. Design: Randomized controlled trial. Setting: Specialised rehabilitation centre. Subjects: A total of 100 patients (mean age of 69 (8) years; 40 males, 60 females). Interventions: The experimental group underwent task-oriented exercises and was encouraged to abandon any walking aids by the end of their in-hospital stay. The control group underwent open chain kinetic exercises, and was recommended to use partial weight-bearing and walking aids until three months after surgery. Both groups individually followed programmes of 90-minute sessions five times a week for three weeks. Outcome measures: Western Ontario and McMaster Universities Osteoarthritis Index, Pain Numerical Rating Scale, Functional Independence Measure, and Short-Form Health Survey. The participants were evaluated before, after training, and after a further 12 months. Results: There were no significant between-group differences at baseline. After training, a between-group difference of 12 points was found for the Western Ontario and McMaster Universities Osteoarthritis Index – functional subscale, indicating a clinically tangible treatment effect on disability. The Functional Independence Measure increased by 31 and 15 points in the experimental and control group, respectively. A linear mixed model revealed significant effects of time, group, and time by group interaction on disability, pain, activities of daily living, and most of the physical quality of life domains. Conclusion: Task-oriented exercises associated with early full weight-bearing improve disability, pain, activities of daily living, and quality of life after total hip replacement.

An attempt to induce transient immunosuppression pre-erythrocytapheresis in a girl with sickle cell disease, a history of severe delayed hemolytic transfusion reactions and need for hip prosthesis

Abstract We report on a case of delayed hemolytic transfusion reaction (DHTR) occurred 7 days after an erythrocytapheresis or eritroexchange procedure (EEX) treated with rituximab and glucocorticoids in a 15-years old patient with sickle cell disease. EEX was performed despite a previous diagnosis of alloimmunization, in order to reduce hemoglobin S rate before a major surgery for avascular necrosis of the femoral head. A first dose of rituximab was administered before EEX. However, rituximab couldn’t prevent DHTR that occurred with acute hemolysis, hemoglobinuria and hyperbilirubinemia. A further dose of rituximab and three boli of methylprednisolone were given after the onset of the reaction. It is likely that the combined use of rituximab and steroids managed to gradually improve both patient’s general conditions and hemoglobin levels. Nor early or late side effects were registered in a 33-months follow-up period. This report suggests the potential effectiveness and safety of rituximab in combination with steroids in managing and mitigating the symptoms of delayed post-transfusional hemolytic reactions in alloimmunized patients affected by sickle cell disease with absolute need for erythrocytapheresis.

Intra-Articular Cytokine Levels in Adolescent Patients after Anterior Cruciate Ligament Tear

The treatment of anterior cruciate ligament (ACL) injuries in children and adolescents is challenging. Preclinical and clinical studies investigated ACL repairing techniques in skeletally immature subjects. However, intra-articular bioenvironment following ACL tear has not yet been defined in skeletally immature patients. The aim of this study was to measure cytokine concentrations in the synovial fluid in adolescent population. Synovial levels of IL-1β, IL-1ra, IL-6, IL-8, IL-10, and TNF-α were measured in 17 adolescent patients (15 boys) with ACL tears who underwent ACL reconstruction including acute (5), subacute (7), and chronic (5) phases. Femoral growth plates were classified as “open” in three patients, “closing” in eight, and “closed” in six. Eleven patients presented an ACL tear associated with a meniscal tear. The mean Tegner and Lysholm scores (mean ± SD) of all patients were 8u2009±u20091 and 50.76u2009±u200926, respectively. IL-8, TNF-α, and IL-1β levels were significantly greater in patients with “open” physes. IL-1ra and IL-1β levels were significantly higher in patients with ACL tear associated with a meniscal tear. Poor Lysholm scores were associated with elevated IL-6 and IL-10 levels. IL-10 levels positively correlated with IL-6 and IL-8 levels, whereas TNF-α concentration negatively correlated with IL-6 levels. Skeletally immature patients with meniscal tears and open growth plates have a characteristic cytokine profile with particularly elevated levels of proinflammatory cytokines including IL-8, TNF-α, and IL-1β. This picture suggests that the ACL tear could promote an intra-articular catabolic response in adolescent patients greater than that generally reported for adult subjects. The study lacks the comparison with synovial samples from healthy skeletally immature knees due to ethical reasons. Overall, these data contribute to a better knowledge of adolescent intra-articular bioenvironment following ACL injuries.

Treatment of hip fracture of Pope Innocent XII by Marcello Malpighi with bed rest

Marcello Malpighi (1628–1694), who is referred to as the father of microscopical anatomy, histology, physiology and embryology was an Italian biologist and physician, well known for his discoveries on microscopical anatomy of kidney, circulating and lymphatic systems. As well as being a brilliant anatomist, Malpighi was also a valued physician so far as to became the personal physician of Pope Innocent XII (1615–1700). On 23 August 1691, one month after his election, the Pope fell to the ground hitting his left hip. Malpighi, as his personal physician, was immediately called and diagnosed a hip fracture. At that time fractures were generally treated by surgeons, barbers and sawbones, while physicians were mainly concerned with internal diseases. Despite that, Marcello Malpighi cured Pope Innocent XIIs hip fracture by applying some modern traumatologic concepts. This article analyses how Malpighi treated this hip fracture, comparing it with the current approach.

Clinical effectiveness of surgical treatment with polyester tapes and temporary K-wires on complete acromioclavicular dislocation

IntroductionIdeal treatment of acute acromioclavicular joint (ACJ) dislocation remains unresolved. We evaluated ACJ reconstruction using polyester tapes and temporary Kirschner wire (KW) and presented clinical and radiological outcomes.Materials and methodsPatients were retrospectively evaluated and classified according to Rockwood classification, clinical and sportive characteristics. Constant Score (CS) and ACJ joint instability (ACJI) score were collected. Zanca’s, Alexander, axillary, standard, and stress AP views were collected. Radiographic coracoclavicular distance (CCd) of healthy and injured shoulders was measured pre-operatively, at 3xa0months and at minimum 2-year follow-up. Heterotopic ossifications and clavicular osteolysis were evaluated. Influence of patients’ characteristics and AC joint type on clinical and radiological outcomes were determined.ResultsSixteen patients (13 type V and 3 type III ACJ dislocation) reached the end of follow-up (mean 2.4xa0years; range 22–72xa0months). Mean CS was 99.63 (range 96–100), while the mean ACJI score was 96.19 (range 85–100). The CCd of the treated shoulder was comparable with the healthy shoulder at 3xa0months and at last follow-up; moreover, there was no difference in CCd scores at 3xa0months and at 2xa0years. CCd scores were lower in sedentary patients compared with physically active (sporty) patients. Heterotopic ossifications were observed in three patients. No osteolysis was reported.ConclusionThis technique provides good results with few complications and should be considered as an effective method to treat ACJ acute dislocation. CCd scores correlate with overuse factors but not with other clinical scores.