John L. Esterhai

Use of Medical Comorbidities to Predict Complications After Hip Fracture Surgery in the Elderly

BACKGROUNDnComorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patients general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery.nnnMETHODSnA retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined.nnnRESULTSnMedical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications.nnnCONCLUSIONSnThe ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

Magnetic Resonance Imaging for the Diagnosis of Osteomyelitis in the Diabetic Patient with a Foot Ulcer

Twenty-seven diabetic patients (12 males and 15 females) with clinically suspected osteomyelitis complicating soft tissue infection of the foot underwent 29 magnetic resonance imaging studies of the suspected lesion. Of these patients, 26 had plain film radiographs, 11 had technetium bone scanning, and 12 had indium-labeled leukocyte scintigraphy performed within 2 weeks of the magnetic resonance imaging. Definitive diagnosis of the presence or absence of osteomyelitis was obtained on the basis of surgical findings, histological evidence, or resolution with nonoperative therapy. Magnetic resonance imaging was 90% accurate (sensitivity 77%, specificity 100%) in the diagnosis of osteomyelitis in this patient population. Technetium bone scan was 45% accurate (sensitivity 100%, specificity 25%); indium-labeled leukocyte scintigraphy was 50% accurate (80% sensitivity, 29% specificity); and plain film roentgenography was 73% accurate (60% sensitivity, 81% specificity). Magnetic resonance imaging is a powerful, noninvasive tool for determining the presence or absence of osteomyelitis in the patient with a diabetic foot ulcer.

Posttraumatic changes in the posterior glenoid and labrum in a handball player

Magnetic resonance imaging evaluation of a handball player with chronic pain in his nondominant shoulder revealed posttraumatic changes in the posterior glenoid and labrum. This provided a pathophysiologic explanation for the patients symptoms.

Is upper extremity trauma an independent risk factor for lower extremity venous thromboembolism? An 11-year experience at a Level I trauma center

IntroductionVenous thromboembolism (VTE) is an important problem in orthopedic trauma patients. An association between VTE and upper extremity injury has not been reported. The purpose of this investigation was to determine whether upper extremity trauma is an independent risk factor for lower extremity VTE. This study also attempted to identify associations between VTEs and demographic and injury variables in patients that sustained upper extremity trauma.MethodsEleven years of data from the trauma registry at our Level I trauma center was retrospectively reviewed in an injury-matched cohort study. From an initial pool of 646 patients who sustained upper extremity trauma, 32 subjects (4.95%) were identified as having major upper extremity injuries as well as thromboembolic complications. Thirty-two injury-matched controls were randomly selected from the 646 patients with major upper extremity injuries. Regression analysis was performed to determine variables that were significantly associated with lower extremity thromboembolic complications.ResultsOverall incidence of VTE in patients sustaining upper extremity injury was 4.95% (deep vein thrombus 4.64%, pulmonary embolism 0.31%) and was similar to the 4.95% VTE rate in patients without upper extremity injury. Major head injury (pxa0=xa00.022) occurred at increased frequency in the VTE group. Patients with increased length of hospital stay (pxa0<xa00.001) and length of time on a ventilator (pxa0=xa00.002) were at significantly higher risk for thromboembolic complications. No patient with isolated upper extremity trauma had complications from VTE.ConclusionLower extremity VTE occurs at similar rates in patients sustaining upper extremity injury compared to those patients that do not. Major upper extremity orthopedic trauma is not an independent risk factor for lower extremity VTE, and current clinical management guidelines for VTE prophylaxis are adequate for patients sustaining major upper extremity trauma.

Osteomyelitis and Septic Arthritis in Adults

Osteomyelitis and septic arthritis can result in considerable morbidity in adults, especially when the diagnosis is delayed. The physiologic status of the host is an important variable, and surgical care is frequently required in addition to antibiotics to eradicate infection and treat complications.

Fractures of the Distal Femur

Fragility fractures of the distal femur pose a challenge for stable internal fixation and good functional outcomes. Among those challenges are frailty of the elderly patient, high degree of osteoporosis, instability of the fracture patterns, short distal femur segment, and amount of comminution. Mortality at 1 year has been reported as high as 30%. Morbidity includes significant decreases in function, quality of life as well as medical and surgical complications. Medical stabilization and optimization are extremely important in this frail population. Non-surgical management is reserved for minimally displaced fractures in the patient who will likely not tolerate the risks of anesthesia or surgical intervention. Surgical treatment, which is the favored treatment, is necessary to prevent prolonged immobilization and its sequelae. Surgical treatment options include antegrade or retrograde intramedullary nailing, standard lateral plating, the use of fixed angle devices, and total knee arthroplasty. Rehabilitation is necessary and includes early range of motion, strengthening, mobilization, gait training if possible, and prevention of common medical complications.