Shingo Maekawa

Prognosis of proximal femoral fracture in patients aged 90 years and older.

Purpose. To examine the walking ability and survival outcome of patients aged 90 years and older who sustained proximal femoral fractures, and to compare the findings with those of younger patients reported in previous studies. Methods. Between January 1997 and June 2004 inclusive, 56 patients (11 men and 45 women) aged 90 years and older (range, 90–103 years; mean, 93 years) with hip fracture were reviewed. Their walking ability and survival outcome at discharge was investigated. Comparison was made between patients aged 60 to 89 years and those aged 90 years and older with respect to sex, fracture type, and other characteristics. Results. Of 56 patients, 26 injured the right side and 30 the left side. Before injury, 33 (59%) were living at home and 23 (41%) were institutionalised in long-term care facilities or other hospitals. Fracture occurred at the femoral neck in 14 patients and at the trochanter in 42. Ten patients were treated conservatively because of severe dementia, comorbidity, or refusal of surgery by the patients or their families, whereas 46 underwent surgery. Of the 45 who were previously ambulatory, 22 regained walking ability on discharge from hospital. None of the 10 patients treated conservatively were ambulatory on discharge. During hospitalisation, 4 became bedridden and 5 died (mainly due to pneumonia); among these 9 patients, 5 were deemed physically unfit for surgery. Conclusion. Surgery is the treatment of choice for patients aged 90 years and older with proximal femoral fracture. However, they have a lower rate of regaining pre-injury walking ability and a higher in-hospital death rate than younger patients.

Resorption of thoracic disc herniation. Report of 2 cases.

The authors describe 2 cases of thoracic disc herniation, resulting in acute myelopathy without bladder dysfunction or progressive muscular weakness; the herniated disc apparently resorbed without surgical intervention. Thoracic disc herniations are less frequent than cervical or lumbar disc herniations and are usually associated with severe neurological deficits. In these 2 cases, the herniated discs exhibited marked decreases in size, corresponding to a favorable clinical outcome within a few months after the initiation of conservative treatment with prostaglandin E(1) and/or steroids in conjunction with physical therapy. The authors conclude that thoracic herniated discs are capable of undergoing natural resorption and that conservative treatment could be indicated, even in the presence of moderate myelopathy, when the myelopathy is not accompanied by bladder dysfunction or progressive muscular weakness.

Symptomatic spinal epidural lipomatosis with severe obesity at a young age.

Symptomatic spinal epidural lipomatosis is a rare disorder characterized by overgrowth of fat in the extradural space. Most patients have an underlying endocrine disorder, such as Cushings syndrome, or have taken exogenous steroids chronically. Although less common, obesity alone is thought to be a cause of spinal epidural lipomatosis, representing <25% of reported cases. Patients rarely become symptomatic before middle age without chronic exogenous steroid use. The usual clinical manifestations are similar to degenerative lumbar stenosis with neurogenic claudication, resulting in decreased walking and standing endurance with variable neurological deficits.This article describes 2 unique cases of spinal epidural lipomatosis, both in young patients with underlying morbid obesity who presented with acute progressive leg weakness and urinary retention. The patients had no underlying endocrinopathy, nor any history of exogenous steroid use. They underwent emergency laminectomy and removal of epidural fat, and histopathological examination confirmed the diagnosis of epidural lipomatosis. Postoperatively, the patients demonstrated significant improvement.We conducted a review of the available English literature and compared the age distribution in each group. Based on our review, our 2 patients are considerably younger than those in past reports, especially in the patient group to which the steroid was not administered. In addition, few cases exist of spinal epidural lipomatosis with acute sphincter dysfunction and paraparesis. Our cases suggest that morbid obesity can lead to juvenile spinal epidural lipomatosis with acute neurological changes.

Comparison of the prognosis among different age groups in elderly patients with hip fracture.

Background: The outcome of treatment of hip fractures in different age groups in the elderly population is largely unknown. Hence, we stratified elderly patients with hip fracture into age groups and compared the prognosis in various age groups. Materials and Methods: Among 459 patients with hip fracture treated at our hospital from 1997, 430 patients aged 65 years or above at the time of injury were studied. The patients comprised 98 males and 332 females and the ages at injury ranged from 65 to 103 years (mean 83.4 years). There were 167 cases of femoral neck fracture and 263 cases of trochanteric fractures. Surgery was performed in 383 cases, while 47 cases were treated conservatively. The subjects were classified by age into young-old for those aged 65-74 years (group A, n = 55), middle-old for those aged 75-84 years (group B, n = 172), old-old for those aged 85-94 (group C, n = 180), and oldest-old for those aged 95 years or above (group D, n = 23). The functional and survival prognosis at discharge in each group was investigated. Results: Numbers of patients who were ambulatory at discharge among those ambulatory before injury were 43 of 49 (87.8%) in group A, 113 of 152 (74.3%) in group B, 86 of 138 (62.3%) in group C, and 5 of 14 (35.7%) in group D, showing worse recovery of walking ability as age advanced. Among those ambulatory before injury, 42 patients in group A, 139 patients in group B, 130 patients in group C, and 12 patients in group D underwent surgery and of these patients, 38 patients (90.5%) in group A, 109 patients (78.4%) in group B, 83 patients (63.8%) in group C, and 5 patients (41.7%) in group D were ambulatory at discharge. On the other hand, the numbers of patients who were ambulatory at discharge among those receiving conservative treatment were 5 of 7 (71.4%) in group A, 4 of 13 (30.8%) in group B, 3 of 8 (37.5%) in group C, and 0 of 2 (0%) in group D, showing better walking ability in surgical patients than in conservatively treated patients even in the elderly. There were two in-hospital deaths in group B, 11 in group C, and two in group D. Five of the 15 deaths were inoperable cases due to poor performance status at admission. Conclusion: Walking ability at discharge and survival prognosis worsened as age advanced. On the other hand, since surgical cases achieved better walking ability than conservatively treated cases, efforts should be made to achieve better functional prognosis even in the old-olds, including surgery together with early ambulation and rehabilitation.

Twin hook fixation for proximal femoral fractures

Purpose. To report results of twin hook fixation for proximal femoral fractures in comparison to those fixed with the conventional lag screw. Methods. Between August 2005 and July 2006, 2 men and 15 women aged 74 to 94 (mean, 85) years with proximal femoral fractures underwent open reduction and internal fixation using the twin hook system. The tip-apex distance was compared with that in 20 patients treated with the sliding hip screw between August 2004 and July 2005. Results. In the 17 patients, the hook was inserted into the centre of the femoral head. Bone union was achieved and no intra- or post-operative cut-out or device failure was encountered. In patients using the twin hook and sliding hip screw respectively, the mean tip-apex distance was 22.3 mm and 14.6 mm (p<0.001). Conclusion. Using the twin hook system requires more surgical skill than using the sliding hip screw, because failure to insert the pin into the centre of the femoral head risks intra-articular perforation by the hooks.