Complications and their risk factors following hip fracture surgery.

PURPOSE. To evaluate various postoperative complications and their risk factors in hip fracture patients. METHODS. 207 female and 87 male consecutive patients (mean age, 78.1 years) who underwent surgical (n=242) or conservative (n=52) treatment for closed fractures of the femoral neck (n=157) or peritrochanter (n=137) were prospectively studied. The types of complication and outcome were recorded. The comorbidity status of the patients was categorised based on the American Society of Anesthesiologists (ASA) classification. Complications and their associations with various risk factors and mortality were analysed. RESULTS. For all patients, the mean length of hospitalisation was 14.6 days. For the 242 patients who underwent surgical treatment after a mean of 3.6 days, 56.8% of them had at least one complication. Acute urinary retention (39.3%) and urinary tract infection (24.0%) were most common. Patients with ASA grade III or higher had 2.3 fold higher risk of developing complications than those with lower-grade comorbidity, whereas patients with delayed operation (>48 hours after presentation) had 1.8 fold higher risk of developing complications than those without delayed operation. Four patients died in hospital: 2 from myocardial infarction and 2 from upper gastrointestinal bleeding. CONCLUSION. Complications after hip fracture surgery were common. Advanced age, high ASA status, and delay in surgery were associated with higher complication rates. Operations should be performed on medically fit patients as early as possible.

Femoral shaft fractures in the elderly--role of prior bisphosphonate therapy.

INTRODUCTION: There is a recent surge in interest on bisphosphonate related femoral fractures. Most studies have examined subtrochanteric fractures in patients on long-term bisphosphonates. This study evaluates the characteristics of low-impact femoral shaft fractures in elderly patients on long-term alendronate. MATERIALS AND METHODS: All patients above 60 years old admitted to the National University Hospital for femoral shaft fracture from January 2003 to January 2007 were retrospectively analysed. Of the 55 patients included, 7 had prior alendronate therapy and were examined in detail. RESULTS: All 7 patients on prior alendronate therapy sustained their fractures by low-impact or atraumatic mechanisms of injury. 5 of these 7 patients exhibited a characteristic fracture pattern of thickened lateral cortices at the proximal fracture fragment (p<0.05) and all 7 patients had either transverse or short oblique fractures. Notably, none of the 7 patients had bone mineral density scans prior to their fractures. One patient was started on alendronate after a vertebral compression fracture, whilst the other 6 patients were started on alendronate without any clear clinical indication. All 7 patients reported prodromal thigh pain 3 weeks to 2 years prior to the fracture. CONCLUSIONS: Low-impact femoral shaft fractures in elderly patients on long-term alendronate therapy represent a new entity of insufficiency fractures, with characteristic low-impact modes of injury and fracture patterns on radiograph. Prodromal thigh pain is a warning sign for impending fracture in this group of patients and should be evaluated closely. Teriparatide is a possible alternative to alendronate following such a fracture though more long-term clinical studies are required.

The management of severe acetabular bone defects in revision hip arthroplasty using modular porous metal components.

We investigated the early results of modular porous metal components used in 23 acetabular reconstructions associated with major bone loss. The series included seven men and 15 women with a mean age of 67 years (38 to 81), who had undergone a mean of two previous revisions (1 to 7). Based on Paprosky's classification, there were 17 type 3A and six type 3B defects. Pelvic discontinuity was noted in one case. Augments were used in 21 hips to support the shell and an acetabular component-cage construct was implanted in one case. At a mean follow-up of 41 months (24 to 62), 22 components remained well fixed. Two patients required rerevision of the liners for prosthetic joint instability. Clinically, the mean Harris Hip Score improved from 43.0 pre-operatively (14 to 86) to 75.7 post-operatively (53 to 100). The mean pre-operative Merle d'Aubigné score was 8.2 (3 to 15) and improved to a mean of 13.7 (11 to 18) post-operatively. These short-term results suggest that modular porous metal components are a viable option in the reconstruction of Paprosky type 3 acetabular defects. More data are needed to determine whether the system yields greater long-term success than more traditional methods, such as reconstruction cages and structural allografts.

Spontaneous spinal epidural haematoma associated with aspirin intake.

Spontaneous spinal epidural haematoma (SSEH) is rare. No identifiable cause is found in the majority of cases, while anticoagulation accounts for up to 17 percent of cases. Aspirin-associated SSEH, however, has rarely been described in literature. A 62-year-old man on prophylactic aspirin presented with symptoms of acute cord compression due to spinal epidural haematoma that was confirmed on magnetic resonance imaging. An emergency decompression laminectomy was performed ten hours after the onset of his symptoms. No vascular anomaly was detected. Our patient recovered well and regained full motor and sensory function. Aspirin is unlikely to be the direct cause of SSEH but may predispose to it, with the underlying cause being a locus minoris resistentiae, consisting of a network of weakened epidural veins. Early diagnosis and treatment are essential for a successful outcome.

Identification of risk factors for urinary retention following total knee arthroplasty: a Singapore hospital experience.

INTRODUCTION: Urinary retention is associated with an increased rate of urinary tract infections and deep sepsis following total joint arthroplasty. This study was carried out to investigate the incidence of urinary retention following total knee arthroplasty in a Singapore hospital, and to identify risk factors associated with the development of this complication in our patient population. METHODS: The charts of 125 consecutive patients who underwent primary total knee arthroplasty between January and December 2004 were reviewed. The incidence of postoperative urinary retention was correlated with the following factors: age, gender, choice of anaesthesia, duration of surgery, and analgesic technique. Statistical analysis was performed with univariate and multivariate logistic regression models. There were 109 female and 16 male patients. The mean age of the patients was 67.5 years (range, 50-86 years). RESULTS: Ten patients developed urinary retention, giving an overall rate of 8.0 percent (95 percent confidence interval [CI], 3.9-4.2). Male gender (odds-ratio [OR] is 5.9; 95 percent CI, 1.2-29.5; p-value is 0.03) and epidural analgesia (OR is 7.6; 95 percent CI, 1.7-35.0; p-value is 0.009) were found to be the only factors significantly associated with postoperative urinary retention. Patient age, duration of surgery and choice of anaesthesia were not found to be significantly associated with urinary retention. CONCLUSION: In our patient population, male patients and patients receiving epidural postoperative analgesia are at increased risk of developing urinary retention following total knee arthroplasty.

Esophageal intramural pseudodiverticulosis associated with a web in a 12-year-old boy.

Esophageal intramural pseudodiverticulosis (EIPD) is a rare benign disorder characterized by dilation of the submucosal glands. Its etiology and pathogenesis are largely unknown. So far, less than 10 pediatric cases of EIPD have been reported. The authors present the case of a 12-year-old boy with EIPD that was associated with a cervical esophageal web. He was treated successfully with dilation therapy.

Laparoscopic nephroureterectomy in children.

BACKGROUND/PURPOSE: Laparoscopic surgery is playing an increasingly important role in pediatric urology. It has emerged as an alternative means of performing nephroureterectomy. The authors report their experience with laparoscopic nephroureterectomy in children. METHODS: Between July 1996 and August 1997, six patients aged between 3 months and 5 years, 9 months (average, 35 months) underwent laparoscopic nephroureterectomy. The transperitoneal approach was used in all cases. RESULTS: Operating times ranged from 110 to 265 minutes, averaging 176 minutes. No early or late postoperative complications were noted. Five of six patients resumed oral feeding on the first postoperative day. Four of six patients were discharged on the second postoperative day. CONCLUSIONS: Laparoscopic nephroureterectomy is a safe and feasible alternative to the open method in children. It is associated with good surgical results and favorable postoperative patient recovery.