Nutritional status and clinical outcome in elderly female surgical orthopaedic patients.

The possible relationship between nutritional status and clinical outcome following orthopaedic hip surgery was investigated. The nutritional status of 60 elderly female patients admitted for elective total hip replacement (THR) and emergency fractured neck of femur surgery (FNF) was measured over time. Specific measures of clinical outcome, including well-being and functional status, were monitored during hospital stay and at 4, 8 and 26 weeks following discharge. Patients were allocated to a high nutritional risk group where any three of the following were less than the 5th percentile value: serum albumin, haemoglobin, triceps skinfold thickness, mid-upper arm muscle circumference and body weight. Using this definition, malnutrition was present in 4% of THR patients and 41% of FNF patients. It was found that the high risk patients had significantly longer convalescence periods, (median stay 27.5 days compared with 0 days, P < 0.0009), and a greater proportion were dependent upon walking frames at 6 months (46% compared with 11%, P < 0.01). Fifty percent of the high risk patients had been living independently prior to admission, in contrast only 29% had returned to their homes at 6 months after discharge. The results indicate an apparent link between clinical outcome and nutritional status based upon the allocation procedure employed, which has the potential for ensuring cost-effective nutritional intervention.

Subsidence of the femoral component related to long-term outcome of hip replacement.

We compared the clinical outcome with femoral subsidence and radiographic changes in 102 patients at 9 to 13 years after low friction arthroplasty. In 92 cases with a satisfactory outcome there was an average of 2.3 radiological signs and mean subsidence of less than 5 mm. An unsatisfactory outcome was associated with 3.4 signs per film and with subsidence of more than 5 mm. The radiological signs we describe are often the hallmark of successful load transmission, but if they increase with time or are associated with subsidence of over 5 mm, then clinical failure is likely. Fracture of the cement tip is associated with increased subsidence and adversely affects the long-term clinical outcome.

Fluid and electrolyte homeostasis during prolonged exercise at altitude.

The combined effect of exercise and altitude on fluid and electrolyte homeostasis was studied over 13 days on six male subjects eating a diet with constant sodium and potassium content. During the first 4 and last 4 days subjects were semisedentary at an altitude of 900 m. In the middle 5 days subjects exercised by hill walking for about 7 h daily at altitudes between 2,678 and 3,629 m. There was a retention of sodium (mean of 202 mM by the end of the exercise-altitude period) and a small retention of water (mean of 0.49 liters). Plasma volume increased by 0.76 liters and packed cell volume fell from a mean of 44.5 to 41.8%. There was no change in plasma sodium concentration. The retention of sodium implies an expansion in the extracellular space of 1.44 liters at the expense of the intracellular space, which decreased by a calculated 1.05 liters. These changes are similar to those resulting from comparable exercise at sea level and opposite to the effect of altitude on resting subjects.

Sodium balance, fluid homeostasis and the renin-aldosterone system during the prolonged exercise of hill walking.

1. The effect of 5 consecutive days of hill walking on electrolyte balance, fluid homeostasis, plasma renin activity and plasma aldosterone concentration was studied in five male subjects. 2. The 5-day exercise period was preceded by a 4-day control period and followed by a 4-day recovery period. Throughout the 13-day study subjects ate a fixed diet. 3. After 5 days of exercise subjects had retained a mean of 264 mmol (SD 85) of sodium. Plasma sodium concentration remained constant at 142.0 mmol/l (SD 5.4). This indicates an expansion of the extracellular space by 1.84 litres. 4. By the end of the exercise period there was a positive water balance of about 0.9 litre. Thus there was a net movement of 0.94 litre of fluid from the intracellular to the extracellular space. 5. Packed cell volume decreased from a mean of 43.5% to 37.9% after 5 days of exercise, indicating that about 0.9 litre of the extracellular fluid entered the vascular compartment. The remaining fluid may be responsible for the significant increase in lower leg volume. 6. During the exercise period plasma aldosterone concentration and plasma renin activity rose, and there was a highly significant correlation between these values and the sodium retention. There was also a significant correlation between sodium retention and the increase in leg volume, which suggests that oedema may be the result of prolonged exercise of this type.

Thiamine and the elderly orthopaedic patient.

An assessment of thiamine status was made in two groups of elderly orthopaedic patients. None of the 30 men and women presenting for elective total hip replacement was malnourished before operation but there was a significant fall in the thiamine status 48 hours later, which had returned to normal by 14 days. In contrast, the majority of the 34 patients in the second group were thiamine deficient after surgery for a femoral neck fracture and remained so throughout the initial post-operative period of 14 days. In both groups those patients who were noticeably confused after operation were found to have a considerable fall in their thiamine status suggesting this may be a contributory factor to postoperative confusion.

A nutrient survey in elderly women with femoral neck fractures.

This survey was undertaken to study the nutrition of elderly women following surgical treatment for a femoral neck fracture. The voluntary food intake of 19 patients was measured 3, 7 and 14 days after operation. When the nutrient content was calculated and compared with DHSS recommended values for healthy women of the same age, only the intakes of vitamin A and calcium were adequate. The mean intake of protein, energy, vitamin D, riboflavin, vitamin C, thiamin and niacin fell short of the recommendation. The evidence suggests that whilst adequate food intake may be provided in hospital, the actual nutrient intake of elderly female patients recovering from a femoral neck fracture is often inadequate.

Shoulder arthroscopy. Investigations with a fibreoptic instrument.

Ten patients with frozen shoulders and 13 other patients with derangements of the shoulder were examined by arthroscopy. The procedures were performed under anesthesia. A fibreoptic instrument was introduced posteriorly. All patients with frozen shoulders were relieved of their symptoms by the combined procedure of joint distention (with as much as 60 ml of saline) and arthroscopy, with or without manipulation of the shoulder. Three of the 13 cases of imprecisely diagnosed shoulder derangement are described in detail to illustrate refinements in the diagnosis which determined surgical repair in 2 cases and precise local treatment in the other one. All patients, whose shoulders were not manipulated, were discharged to their homes on the day of the procedures. A sling was worn for the first 24 hr and then the patient was placed on a regimen of supervised physical therapy. There was no significant morbidity in these patients. Additional refinements in arthroscopy for the shoulder and increasing expertise in using the techniques will firmly establish arthroscopy as a means for establishing precise diagnoses fro shoulder conditions.

Effect of the exercise of seven consecutive days hill-walking on fluid homeostasis.

1. The effect of 7 consecutive days of strenuous exercise, hill-walking, on water balance and distribution was studied in five subjects. The exercise was preceded and followed by 3 control days. The diet was fixed throughout but water was allowed ad libitum. 2. Packed cell volume was measured daily. Serum electrolytes and arginine vasopressin were measured twice daily. Daily water, sodium and potassium balances were calculated. 3. During exercise there was a fall in packed cell volume, reaching a maximum of 11% by day 5 and a retention of sodium reaching a cumulative maximum of 358 mmol by day 6. During and immediately after exercise there was a retention of potassium, reaching a total of 120 mmol by day 3 after stopping exercise. 4. There was a loss of 650 ml of water on day 1 of exercise, followed by a modest retention reaching a cumulative maximum of 650 ml on day 5 of exercise. 5. Neither arginine vasopressin nor serum electrolyte concentrations were affected by exercise. 6. From the packed cell volume, sodium and water balances it was calculated that by day 5 of exercise there was an increase in plasma volume of .068 litre (22%), an increase in interstitial fluid volume of 2.0 litres (17%) and a decrease in intracellular fluid volume of 1.8 litres (8%). 7. These changes, together with the clinical observation of facial and ankle oedema during the experiemnt, suggest that continuous exercise may cause oedema and thus may be a factor in the aetiology of high-altitude oedema.

Distension arthrography of the shoulder joint.

Pain and stiffness resulting from degenerative disease of the rotator cuff of the glenohumeral joint is not always self-limiting. In a few patients, the symptoms persist despite medication and physiotherapy. Distension arthrography, a method of hydrostatic manipulation, has been used in six such patients; five recovered full range of abduction and rotation and the sixth was improved. It is concluded that distension arthrography should be part of the treatment of intractable pain stiffness of the shoulder joint.