Neck of femur fractures in the over 90s: a select group of patients who require prompt surgical intervention for optimal results.

BACKGROUND: Patients in the extremes of old age with a femoral neck fracture represent a challenging subgroup, and are thought to be associated with poorer outcomes due to increased numbers of comorbidities. Whilst many studies are aimed at determining the optimum time for surgical fixation, there is no agreed consensus for those over 90. The aim of this study is to report the surgical outcome of this population, to understand the role surgical timing may have on operative outcomes using the orthopaedic POSSUM scoring system and to identify whether medical optimization occurs during the period of admission before surgery. MATERIALS AND METHODS: We conducted a prospective observational study; data was collected from two district general hospitals over 32 consecutive months. All patients aged 90 and above who were deemed suitable for surgical fixation were included. Each one had their orthopaedic POSSUM score calculated at admission and at surgery, using their computerised and paper medical records. Assessment of outcome was based on morbidity and mortality at 30 days. RESULTS: A total of 146 consecutive patients above the age of 90 underwent surgery and were followed. The average age of the patients was 93 years, 123 (84 %) were female and 23 (16%) male. Sixty-one patients were operated on within 24 h from admission, 52 patients within 24 and 48 h and 33 had surgery after 48 h from admission. In total, 21 deaths (14.4%) were recorded and 81 patients (55.5%) had a post-operative complication within 30 days. The orthopaedic POSSUM scoring system predicted 30-day mortality in 23 patients and morbidity in 83 patients. This gave observed to predicted ratios of 0.91 and 0.98 respectively. Overall, there was a small improvement in physiological scores taken just prior to surgery compared to those at admission. Mortality and morbidity rates were higher for those operated on or after 24 and 48-h cutoffs compared to those proceeding to surgery within 24 h (P = 0.071 and P = 0.021 respectively and P = 0.048 and P = 0.00011 respectively). When stratified according to their POSSUM scores, patients with scores of 41+ and surgery after 48 h had a significantly higher mortality rate than if they had surgery earlier (P = 0.038). Morbidity rates rose after 24 h of surgical delay (P = 0.026). Patients with a total POSSUM score between 33 and 40 exhibited a higher morbidity after a 24-h delay to surgery (P = 0.0064). CONCLUSION: As life expectancy increases, older patients are becoming commoner in our hospital systems. We believe the orthopaedic POSSUM scoring system can be used as an adjuvant tool in prioritising surgical need, and allow for a more impartial evaluation when changes to practice are made. Our findings show that timing of surgery has an important bearing on mortality and morbidity after hip surgery, and older patients with higher orthopaedic POSSUM scores are sensitive to delays in surgery.

Bone mineral density after the removal of intramedullary nails: a cross-sectional and longitudinal study.

We measured bone mineral density (BMD) using dual X-ray absorptiometry (DXA) at several sites in both fractured and nonfractured limbs in eight patients with femoral shaft fracture and six with tibial shaft fracture at the time of the intramedullary (IM) nail removal. Seven patients were followed up for an average of 13 months. The BMD at the proximal part of the femur and tibia was from 3% to 11% lower in the fractured side as compared to the nonfractured side. The greatest bone loss (13%-21%) was found in the operated distal tibia of the patients with tibial shaft fractures. At the fracture site of the femur, BMD was 10.5% ( P < 0.05) higher, possibly owing to fracture callus formation, whereas tibial shaft BMD was not increased. However, a calculated apparent volumetric BMDvol at the fracture site was 15%-16% decreased. Although BMDs of the fractured side almost reached the baseline level of the nonfractured side (96.9%-102.1%) by the final follow-up (>12 months), the absolute deficit was still 3%-9%. Surprisingly, significant BMD increases (5%-6%) were also detected in all proximal femoral measurement sites of the contralateral limb, which indirectly suggests that the uninjured limb may also suffer from bone loss after lower-extremity trauma. We conclude that clinically important bone loss exists in the proximal femur and proximal and distal tibia of the fractured limb at the time of IM nail removal. Although areal BMD was higher at the femoral fracture site, the lower apparent volumetric BMDvol suggests decreased mineralization and reduced strength of the fracture site. Although the present results do not suggest special recommendations for restricted weight bearing after the removal of IM nails, the relationship between decreased bone density and increased risk of fractures should be borne in mind.

Is titanium so bad? Medium-term outcome of cemented titanium stems.

Early failures have seen titanium fall from favour as a material for cemented femoral stems. Between 1989 and 1994, we performed a prospective review of a consecutive series of 122 cemented total hip replacements using the Ultima straight textured titanium stem, and report the five- to ten-year clinical and radiological outcomes. There were no revisions for loosening of the femoral stem. Revision surgery was undertaken for other reasons such as dislocation, infection and loosening of the cup in 7.3%. Of those patients without revision all but two were satisfied with their hip, with 74% graded good or excellent using a modified Harris hip score. Radiological assessment revealed probable loosening in two. Although slight vertical subsidence was found in one-third of patients it had not progressed to loosening. It is not clear whether this represents debonding. Non-progressive radiolucent lines (1 to 2 mm) were present in zone 1 at the cement-prosthesis interface in 14.7%. Calcar resorption and hypertrophy around the distal stem were not often seen. With 97% survival at a mean of 7.5 years, the medium-term results of this specific cemented titanium stem are reassuring so far, but we are concerned about debonding and future failure.

Do obese patients bleed more? A prospective study of blood loss at total hip replacement.

This study compares blood loss at total hip replacement in obese and non-obese patients. We made a prospective study of intra-operative and postoperative blood loss in 80 consecutive primary cemented hip replacements. Patients' obesity was classified according to body mass index (BMI). Overall mean total blood loss was 1050 ml. Obese patients (BMI > 30) bled significantly more (P < 0.0001) than those of optimal weight (BMI < 26), whereas those overweight (BMI 26-30) did not. The mean excess blood loss in obese patients was 380 ml (95% confidence interval, 200-560 ml). At a time when the prevalence of obesity is increasing, this study quantifies the risks of greater blood loss with respect to obesity and aids informed consent.

The significance of an absent ankle reflex.

We assessed the prevalence of abnormal ankle reflexes in 1074 adult patients attending orthopaedic clinics and related it to age. Those with possible pathological causes of reflex loss were excluded. The absence of one or both reflexes was significantly related to increasing age; all patients under 30 years had both reflexes. Few had absent reflexes between 30 and 40 years, but over 40 years, the proportion with both reflexes absent increased rapidly from 5% (40 to 50 years) to 80% (90 to 100 years). Unilateral absence did not show the same pattern of increase being 3% to 5% at 40 to 60 years and 7% to 10% at over 60 years. Our results suggest that a significant number of 'normal' adults have unilateral absence of an ankle reflex, but this finding is rare enough to be a definite clinical sign, irrespective of age.

The thin tube pedicle: a valuable technique in auricular reconstruction after trauma.

We describe a three staged method of reconstruction for partial helical rim defects using a thin post auricular tube pedicle. The technique is illustrated by three case reports.

Ascorbate free-radical reduction by glyoxysomal membranes.

Glyoxysomal membranes from germinating castor bean (Ricinus communis L. cv Hale) endosperm contain an NADH dehydrogenase. This enzyme can utilize extraorganellar ascorbate free-radical as a substrate and can oxidize NADH at a rate which can support intraglyoxysomal demand for NAD(+). NADH:ascorbate free-radical reductase was found to be membrane-associated, and the activity remained in the membrane fraction after lysis of glyoxysomes by osmotic shock, followed by pelleting of the membranes. In whole glyoxysomes, NADH:ascorbate free-radical reductase, like NADH:ferricyanide reductase and unlike NADH:cytochrome c reductase, was insensitive to trypsin and was not inactivated by Triton X-100 detergent. These results suggest that ascorbate free-radical is reduced by the same component which reduces ferricyanide in the glyoxysomal membrane redox system. NADH:ascorbate free-radical reductase comigrated with NADH:ferricyanide and cytochrome c reductases when glyoxy-somal membranes were solubilized with detergent and subjected to rate-zonal centrifugation. The results suggest that ascorbate free-radical, when reduced to ascorbate by membrane redox system, could serve as a link between glyoxysomal metabolism and other cellular activities.

Characterization of membrane-bound electron transport enzymes from castor bean glyoxysomes and endoplasmic reticulum.

Membranes purified from castor bean endosperm glyoxysomes by washing with sodium carbonate exhibited integral NADH:ferricyanide and NADH:cytochrome c reductase activities. The enzyme activities could not be attributed to contamination by other endomembranes. Purified endoplasmic reticulum membranes also contained the redox activities; and marker enzyme analysis indicated minimum cross contamination between glyoxysomal and endoplasmic reticulum fractions. The glyoxysomal redox activities were optimally solubilized at detergent to protein ratios (weight to weight) of 10 (Triton X-100), 50 (3-[3-cholamidopropyl)-dimethylammonio]-1-propanesulfonate), and 100 (octylglucoside). Detergent in excess of the solubilization optimum was stimulatory to NADH:ferricyanide reductase and inhibitory to NADH:cytochrome c reductase. Endoplasmic reticulum redox activity solubilization profiles were similar to those obtained for glyoxysomal enzymes using Triton X-100. Purification of the glyoxysomal and endoplasmic reticulum NADH:ferricyanide reductases was accomplished using dye-ligand affinity chromatography on Cibacron blue 3GA agarose. Sodium dodecyl sulfate-polyacrylamide gel electrophoretic analysis of NADH:ferricyanide reductase preparations purified by rate-zonal density gradient centrifugation, affinity chromatography, and nondenaturing electrophoresis of detergent-solubilized glyoxysomal and endoplasmic reticulum membranes consistently displayed 32- and 33-kDa silver-stained polypeptide bands, respectively.

Effects of MHz ultrasound on electrical pain threshold perception in humans.

An electrode system was developed consisting of two 8 mm long 0.2 mm diameter silver-coated copper wires arranged parallel to each other 8 mm apart and held in contact with the skin by means of an acoustically transparent plastic adhesive tape. This system was attached to the upper arms of young adult volunteers who increased the voltage of the rectangular electrical pulses supplied to the electrodes until a reproducible sharp prickling pain sensation was perceived. A one inch diameter physiotherapy transducer was positioned over the electrode site so that ultrasound could be administered throughout the measurement period. The experiments were performed single blind to eliminate any subjective bias on the part of the volunteers. Preliminary experiments established that highly reproducible (+/- 3 to 4%) pain threshold perception values could be obtained, and that these values were not affected by changes in (a) the duration of the "on" time of the electrical pulses between 1.5 and 48 ms, (b) the contact pressure between the transducer and the electrode site, (c) the time interval between successive threshold measurements (providing that an unacceptable level of oedema was not produced around the electrodes), and (d) whether or not a test measurement was preceded by a control. Ultrasound exposure via a direct contact technique consistently produced a statistically significant (p less than 0.05) decrease in the perception threshold for electrical pain. This effect usually developed within 30-60 s and its magnitude increased both with increasing intensity (rising to 20.7 +/- 0.57% at an SATA intensity of 0.43 W/cm2 at 1.1 MHz) and with increasing frequency at the same ultrasonic intensity. Delivering the same amount of ultrasonic energy in the form of 2 ms bursts at several different peak intensities produced exactly the same reduction in pain threshold perception. These results indicate a thermal interaction mechanism, and similar threshold changes could be obtained by heating or cooling the electrode site by nonacoustic means. The inclusion of a thermocouple junction between the electrode wires showed that temperature increases of up to 10 degrees C could be produced when the transducer was in direct contact with the tape over the electrodes. The volunteers were not aware of these temperature increases which were primarily caused by heating of the transducer face. If the temperature of the skin surface is kept constant by interposing a thermostatted water path between the transducer and the electrode system, then similar ultrasound exposures had no detectable effects upon the electrical pain perception threshold.(ABSTRACT TRUNCATED AT 400 WORDS)