Michael Krasheninnikoff

The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery

BACKGROUND: Perioperative anemia leads to increased morbidity and mortality and potentially inhibits rehabilitation after hip fracture surgery. As such, the optimum transfusion threshold after hip fracture surgery is unknown.

Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do? †

The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.

A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1 year.

Background and purpose Preoperative posterior tilt in undisplaced (Garden I–II) femoral neck fractures is thought to influence rates of reoperation. However, an exact method for its measurement has not yet been presented. We designed a new measurement for posterior tilt on preoperative lateral radiographs and investigated its association with later reoperation. Patients and methods A consecutive series of 113 patients, ≥ 60 years of age with undisplaced (Garden I–II) femoral neck fractures treated with two parallel implants, was assessed regarding patient characteristics, radiographs, and rate of reoperation within the first year. In a subgroup of 50 randomly selected patients, reliability tests for measurement of posterior tilt were performed. Results Intra-and interclass coefficients for the new measurement were ≥ 0.94. 23% (26/113) of patients were reoperated and increased posterior tilt was an accurate predictor of failure (p = 0.002). 14/25 of posteriorly tilted fractures ≥ 20° were reoperated, as compared to 12/88 of fractures with less tilt (p < 0.001). In multiple logistic regression analysis including sex, age, ASA score, cognitive function, new mobility score, time from admission to operation, surgeons expertise, postoperative reduction, and implant positioning, a preoperative posterior tilt of ≥ 20° was the only significant predictor of reoperation (p < 0.001). Interpretation The new measurement for posterior tilt appears to be reliable and able to predict reoperation in patients with undisplaced (Garden I–II) femoral neck fractures.

A new algorithm for hip fracture surgery. Reoperation rate reduced from 18 % to 12 % in 2,000 consecutive patients followed for 1 year.

Background and purpose Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results. Methods 2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were prospectively included. 1,000 of these patients were included after implementation of the algorithm. Demographic parameters, hospital treatment, and reoperations within the first postoperative year were assessed from patient records. Results 931 of 1,000 operative procedures were performed according to the algorithm, as compared to only 726 of 1,000 prior to its introduction (p < 0.001). After implementation of the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192 of 1,000 to 105 of 1,000 (p < 0.001). The rate of reoperations declined from 18% to 12% (p < 0.001 in a multiple Cox regression analysis), with a decline of 24% to 18% for intracapsular fractures and a decline of 13% to 7% for extracapsular fractures. The proportion of bed-days caused by reoperations was reduced from 24% of total hospitalization before the algorithm was introduced to 18% after it was introduced. Interpretation It is possible to implement an algorithm for treatment of all hip fracture patients in a large teaching hospital. In our case, the Hvidovre algorithm both raised the rate of supervision and reduced the rate of reoperations. The reduced reoperation rate saved many hospital bed-days.

Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year.

Background and purpose In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fractured lateral femoral walls, where it often led to lack of healing in a maximally telescoped position. We hypothesized that INs would be the superior implant in these specific circumstances. Methods We retrospectively examined 311 consecutive patients treated in our department between 2002 and 2008, with either an IN (n = 158) or an SHS (n = 153) mounted on a 4-hole side-plate, for an AO/OTA type 31A1–2 pertrochanteric fracture with a detached greater trochanter. The status of the lesser trochanter was assessed preoperatively and the integrity of the lateral femoral wall, fracture reduction, and position of the implants were assessed postoperatively. Reoperations due to technical failure were recorded for one year postoperatively. Results Multivariate logistic regression analysis showed that the groups were similar regarding demographic and biomechanical parameters. The lateral femoral wall was more frequently fractured during SHS implantation (42 patients) than in the IN group (9 patients) (p < 0.001). 6 (4%) of the 158 patients operated with IN had to be reoperated, as compared to 22 (14%) in the SHS group of 153 patients (p = 0.001). Interpretation IN had a lower reoperation rate than SHS in these pertrochanteric hip fractures with a detached greater trochanter. IN left more lateral femoral walls intact.

Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast

In a prospective study, we randomly allocated 39 patients with isolated fractures of the lower two-thirds of the ulnar shaft to treatment either by a prefabricated functional brace or a long-arm cast. Significantly better wrist function and a higher percentage of satisfied patients were found in the braced group. Thirteen patients returned to employment while still wearing the brace but only one was able to work in a cast.

An enhanced treatment program with markedly reduced mortality after a transtibial or higher non-traumatic lower extremity amputation.

Background and purpose — Historically, high 30-day and 1-year mortality post-amputation rates (> 30% and 50%, respectively) have been reported in patients with a transtibial or higher non-traumatic lower extremity amputation (LEA). We evaluated whether allocating experienced staff and implementing an enhanced, multidisciplinary recovery program would reduce the mortality rates. We also determined factors that influenced mortality rates. Patients and methods — 129 patients with a LEA were consecutively included over a 2-year period, and followed after admission to an acute orthopedic ward. Mortality was compared with historical and concurrent national controls in Denmark. Results — The 30-day and 1-year mortality rates were 16% and 37%, respectively, in the intervention group, as compared to 35% and 59% in the historical control group treated in the same orthopedic ward. Cox proportional harzards models adjusted for age, sex, residential and health status, the disease that caused the amputation, and the index amputation level showed that 30-day and 1-year mortality risk was reduced by 52% (HR =0.48, 95% CI: 0.25–0.91) and by 46% (HR =0.54, 95% CI: 0.35–0.86), respectively, in the intervention group. The risk of death was increased for patients living in a nursing home, for patients with a bilateral LEA, and for patients with low health status. Interpretation — With similarly frail patient groups and instituting an enhanced program for patients after LEA, the risks of death by 30 days and by 1 year after LEA were markedly reduced after allocating staff with expertise.