Rudi Hiebert

Autoimmune-Associated Congenital Heart Block: Demographics, Mortality, Morbidity and Recurrence Rates Obtained From a National Neonatal Lupus Registry

OBJECTIVES The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus. BACKGROUND Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease. RESULTS The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS. CONCLUSIONS Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures

Objective: Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing. Design: Retrospective chart and radiographic review. Setting: Three, level 1, trauma centers. Patients: Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation. Outcome Measures: Malalignment of the tibial shaft was defined as 1) >5° of varus/valgus angulation, or 2) >10° anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined. Results: Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275). Conclusions: In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.

Treatment of external fixation pins about the wrist: a prospective, randomized trial.

BACKGROUND Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment. METHODS One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated. RESULTS The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04). CONCLUSIONS We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures.

A functional recovery score for elderly hip fracture patients: I. Development.

OBJECTIVE To develop a Functional Recovery Score for ambulatory elderly hip fracture patients related to independent functioning to assess restoration of function to prefracture status. STUDY DESIGN/METHODS The phases of this effort consisted of: (a) identification of five relevant components represented by sixteen specific functional capacities; (b) assessment of the importance independent community-dwelling elderly gave to the sixteen functional capacities; (c) pilot testing of a sixteen-item preliminary questionnaire in recovering elderly hip fracture patients; and (d) modification of the questionnaire to an eleven-item score. RESULTS The resulting eleven-item Functional Recovery Score is comprised of three main components: basic activities of daily living (BADL) assessed by four items, instrumental activities of daily living (IADL) assessed by six items, and mobility assessed by one item. Basic activities of daily living comprise 44 percent of the score; instrumental activities of daily living comprise 23 percent, and mobility comprises 33 percent. Complete independence in basic and instrumental activities of daily living and mobility results in a score of 100 percent.

Association of Comorbidity and Outcome in Episodes of Nonspecific Low Back Pain in Occupational Populations

We examined the relationship between comorbidity and first return to work after episodes of work-disabling, nonspecific low back pain (NSLBP). An inception cohort of workers with new episodes of NSLBP was identified from administratively maintained occupational health records. We compared 6-month return-to-work rates between workers with one or more comorbid conditions with those without documented comorbidity. Workers with comorbidity were 1.31 times more likely to remain work disabled than those with uncomplicated NSLBP, after adjusting for age, gender, lifting demands, and company membership (adjusted hazards ratio [HR] = 1.31; 95% confidence interval [CI] 1.12 to 1.52). Concurrent injury (ie, sprains or strains of the neck, upper extremity, and lower extremity; contusions; and lacerations) had the strongest association (adjusted HR = 1.49; 95% CI, 1.21 to 1.83), followed by musculoskeletal disorders (adjusted HR = 1.13; 95% CI, 0.77 to 1.66). Comorbidities should be routinely evaluated at first visit by occupational health professionals to better manage disability associated with LBP.

The effects of weather and seasonality on hip fracture incidence in older adults.

This study examined the effect of weather and seasonality on hipfracture incidence in older adults residing in New York City. A total off 66,346 patients aged > or = 65 years who sustained a fracture of the femoralneck or intertrochanteric region from 1985 to 1996 comprised the study population. Hip fractures were more likely to occur in the winter than in any of the other seasons (P<.001). Factors significantly correlated with hip fractureincluded minimum daily temperature (r=.167, P<.001), daily wind speed (r=.166, P<.001), maximum daily temperature (r=.155, P<.001), minutes of sunshine (r=.067, P<.01), and average relative humidity (r=.033, P=.03). A greater number of hip fractures occurred in colder months, withambient temperature rather than any adverse circumstances related to rainor snowfall associated most closely to injury. As most fractures occurredindoors, precipitation is less likely to play a part in hip fracture occurrence in this population.

Work restrictions and outcome of nonspecific low back pain.

Study Design. Retrospective cohort study was conducted. Objective. To evaluate the association of prescribed work restrictions with work absenteeism and recurrence in cases of nonspecific low back pain. Summary of Background Data. The efficacy of commonly prescribed work restrictions in limiting sickness-related absence because of back pain has not been evaluated. Methods. Employees who had back pain–related sickness absence were identified from medical records of a utility company. The workers were grouped into those who had received a work restriction for their back pain and those who had not. The duration of work disability was compared between the two groups. Employees who returned back to regular, full duty within 1 year of onset were followed for one additional year to determine rates of recurrence. The Cox Proportional Hazards model was used to generate hazard ratios adjusted for age, gender, and job category. Results. Restrictions were given to 43% of the workers. Sickness absence duration did not differ between those who had received restrictions and those who had not (adjusted hazard ratio, 1.12;P = 0.41). The median duration of restricted duty was 32.5 days. For 22% of the workers, restricted duty was never lifted. Recurrence appeared less likely to occur among those who had work restrictions in their initial episode. However, this difference was not statistically significant (adjusted hazard ratio, 0.77;P = 0.48). Conclusions. No evidence of an association between a prescription of work restriction and early return to work was found. More research is needed to clarify the utility of restricted duty in promoting a positive outcome for work-related low back pain.

Tape blisters following hip surgery. A prospective, randomized study of two types of tape.

BACKGROUND Tape blisters after hip surgery can be a source of postoperative morbidity and can increase patient discomfort. The purpose of this prospective study was to compare two different types of tape to determine whether the type of tape influences the rate of blister formation. METHODS Ninety-nine patients (100 hips) were enrolled in the study. Patients were randomized into one of two treatment groups: one treated with a nonstretchable silk tape and one treated with a perforated, stretchable cloth tape. After surgery, the assigned tape was applied over the postoperative dressing with care not to produce skin tension. At the first dressing change, the presence or absence of blisters was recorded as were the number, size, location, and type of any blisters. The presence or absence of tape blisters was recorded at the time of each subsequent dressing change. RESULTS A tape blister developed on twenty-five hips in twenty-five patients. The risk of a blister developing was 41% (twenty of forty-nine patients) when the nonstretchable silk tape was used and 10% (five of fifty patients) when the perforated cloth tape was used (relative risk = 4.08, 95% confidence interval = 1.53 to 10.87, p = 0.005). We found no association between formation of tape blisters and the age or gender of the patient, number of medical comorbidities, smoking history, results of nutritional assessment, or type of surgery. CONCLUSIONS The prevalence of tape blisters was significantly lower when perforated cloth tape was used than it was when nonstretchable silk tape was used.

Can external fixation maintain reduction after distal radius fractures

BACKGROUND The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction. METHODS Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance. RESULTS Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction. CONCLUSION Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients.

Predictors of Discharge to a Skilled Nursing Facility following Hip Fracture Surgery in New York State

Background: Hip fracture is always a very traumatic event, especially for an older person. Often, it is followed by a marked decrease in the level of functioning a patient is able to achieve after recovery. It is even more debilitating when a previously independent person must be discharged to an institution. Objective: This study examined factors and trends associated with discharge to a skilled nursing facility following hip fracture surgery. Methods: Data were analyzed for 89,723 hip fracture patients admitted in New York State from 1986 to 1996. Factors examined included age, gender, race, type of fracture, surgical technique, comorbidities, length of hospitalization and year of admission. Results: Thirty-five percent (32,130) of the patients were discharged to skilled nursing facilities. They tended to be 85+ years old, female, white, have 3+ comorbidities, a history of dementia, have sustained an intertrochanteric fracture, and have been admitted after 1990. In addition, there was a gradual increase in institutionalizations after 1990. Conclusion: In this study, factors were found that predicted discharge to skilled nursing facilities following hip fracture.