Reducing Hypotension and Acute Kidney Injury in the Elective Total Joint Arthroplasty Population: A Multi-Disciplinary Approach.

BACKGROUND: When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. METHOD: A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). RESULTS: In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). CONCLUSION: By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.

Two-screw femoral neck fracture fixation: a biomechanical analysis of 2 different configurations.

In the study reported here, we evaluated 2-screw femoral neck fixation. Femoral necks from 5 paired fresh-frozen cadavers were fractured and then fixed with two 7.3-mm cannulated cancellous screws. Vertical (parallel screws in sagittal plane of femoral neck) and horizontal (parallel screws in superior aspect of femoral neck) configurations were used for each matched pair. Mechanical testing was performed. Load, displacement, and stiffness at the yield point were significantly higher in the horizontal group, which also had a higher mean maximal failure load (P = .019). Preliminary data suggest that 2 horizontal screws in the superior aspect of the femoral neck provide more secure fixation than 2 vertical screws.

Arthroscopically-assisted removal of retrograde intramedullary femoral nails.

Retrograde nailing of femoral shaft fractures has become more prevalent as a result of its growing acceptance and familiarity to orthopaedic surgeons. Nail removal is occasionally indicated, which may require a formal arthrotomy. We describe an arthroscopic removal technique that has several advantages. The percutaneous technique imparts less morbidity than a more extensive arthrotomy. More importantly, additional intra-articular pathology can be thoroughly assessed and treated, such as meniscal tears and chondral injury, which may have occurred at the time of injury. These are potential causes of knee pain, which usually cannot be properly diagnosed without arthroscopy. Our findings also support the existence of a stable fibrous cap, which forms over the entry portal of a well-seated retrograde femoral nail as well as no evidence of intra-articular metallosis.

Cytokines in patients with polytrauma.

Patients with multiple injuries have alterations in hemodynamic, metabolic, and immune responses that largely are orchestrated by endogenous mediators referred to as cytokines. At the molecular level cytokines act as architects constructing a blueprint which ultimately will become the clinical "Big Picture"; however, the exact role and extent each cytokine has is still in question. In addition, the surface of research opportunities has nearly been scratched regarding the best way to control or manipulate the cytokine response in efforts to improve care for the trauma patient. Systemically organisms respond to injury regardless of the cause (hemorrhage, ischemia, reperfusion, fracture, and tissue damage) by attempting to restore homeostasis, which involves a coordination of the immune, cardiovascular, endocrine, and nervous systems. This systemic response can result in severe immunologic compromise that threatens the survival of patients with trauma. It seems that it is this balance or imbalance of cytokines, along with other associative factors, that controls the eventual clinical pathway a patient will take. Blood mediator concentrations often parallel the inflammatory process, and high levels of cytokines can be followed by severe organ dysfunction. Certain cytokine levels, such as the interleukins, can be used in predictive ways to correlate organ failure in multiply injured patients. Although much more research must be done, there is great promise in the study of cytokines through basic science research and clinical trials.

Organizing the orthopaedic trauma association mass casualty response team.

Physicians and surgeons in the United States have become increasingly aware of the requirement for an organized response to mass casualty and disaster situations. This has not always been the case. The terrorist acts in Oklahoma City in 1995 and at the World Trade Center in 1993 and 2001 showed the inefficiencies and confusion of the civilian managed disaster response. Trauma surgeons are uniquely suited to play a leadership role in the planning and coordination of disaster care because of their integration in prehospital emergency medical systems and trauma centers. The Orthopaedic Trauma Association has developed strategies to facilitate the orthopaedic response to mass casualties and to develop an educated approach to disaster management. The current initiatives include the establishment of a link with the American College of Surgeons Committee on Trauma in addition to the development of training programs for orthopaedic surgeons as responders to disaster and mass casualty situations. A team of volunteer orthopaedic traumatologists also has been credentialed to become part of the National Disaster Medical System's International Medical-Surgical Response Team.