The correlates of post-surgical haematoma in older adults with proximal femoral fractures.

BACKGROUND: Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients. AIMS: This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients. METHODS: Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma. RESULTS: Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.

Surgical delay is a risk factor of delirium in hip fracture patients with mild-moderate cognitive impairment.

AIM: To investigate the relationship between onset of delirium and time to surgery in hip fracture (HF) patients with a different degree of cognitive impairment. METHODS: Retrospective analysis of a prospective database of 939 older adults, aged ≥ 75 years admitted with a fragility HF. Subjects underwent a Comprehensive Geriatric Assessment on admission, evaluating health status, prefracture functional status in basic and instrumental activities of daily living, and walking ability. According to the Short Portable Mental Status Questionnaire score, patients were stratified into three categories: cognitively healthy (0-2 errors), mildly to moderately impaired (3-7 errors) and severely impaired (8-10 errors). Time to surgery (from admission) was expressed as days. The occurrence of delirium was ascertained daily by Confusion Assessment Method. RESULTS: Two hundred ninety-two (31.1%) patients experienced delirium during in-hospital stay. They were older, with a higher degree of comorbidity and functional impairment compared to patients without delirium. In multivariate analysis, surgical delay resulted a significant independent risk factor for delirium (HR 1.11, 95% CI 1.01-1.24), along with age, prefracture functional disability and cognitive impairment. When the analysis was performed accounting for the cognitive categories, surgical delay demonstrated to increase the risk of delirium only in the subcategory of mildly to moderately impaired patients, while no significant effect was demonstrated in patients cognitively healthy or severely impaired. CONCLUSIONS: The study supports the concept that older adults with HF should undergo surgery quickly. Patients with mild-to-moderate cognitive impairment should be primarily considered as the best target for interventions aiming to reduce time to surgery.

Treatment of pincer-type femoroacetabular impingement.

Pincer femoroacetabular impingement (FAI) consists of pathological contact between the acetabular labrum and rim and the femoral head-neck junction. Manifold conditions underlie pincer FAI: anatomical abnormalities, malorientation of the acetabulum, torsional abnormalities of the neck and femoral shaft (these defects can be constitutional, post-traumatic or post-surgical), and involvement in sports characterized by repeated and sudden maximum joint excursions. In a high percentage of cases, pincer FAI is associated with cam FAI. The aims of surgical treatment of pincer FAI are to eliminate the cause of the contact and repair the joint damage; the surgery may be open or arthroscopic, performed with an articular or extra-articular approach. Recently, arthroscopic treatment of FAI had a rapid and widespread diffusion due to the advantages it offers compared with the open technique. Arthroscopic treatment can repair the joint damage and in some cases, characterized by minor deformity, compensate for extra-articular defects. The acetabular labrum must always be preserved and sutured; only in extreme cases can it be sacrificed. Post-operative mobilization must respect the healing time of the labral repair.

Successful surgical treatment of a four part fracture dislocations of the proximal humerus and coracoid avulsion.

racture-dislocation of the proximal humerus (usually occurring after violent trauma) may be more frequently associated with a poor long-term results because the destruction of the hinged periosteum is associated with an high-risk of avascular necrosis of the head of the humerus (1, 2). Concomitant coracoid fracture with anterior shoulder dislocation in such case is something extremely rarely reported (8). Herein, we describe a challenging case of a 44 years old man with 4-parts fracture of the right proximal humerus, dislocation of the glenohumeral joint associated with coracoid avulsion. Considering the severe functional damage on the right shoulder, the patient was immediately treated with open reduction internal fixation (ORIF) at the level of the proximal humerus and with the concomitant placement of one screw at the level of coracoid avulsion. At a 15 months follow up we observed an excellent clinical and radiographic results. We take the opportunity of this unusual case for briefly discuss on such clinical condition and surgical options. (www.actabiomedica.it).

Acute posterior shoulder dislocation with reverse hill-sachs lesion of the epiphyseal humeral head.

Posterior dislocation of the shoulder is an unfrequent event that often occurs as a consequence of a direct trauma or epileptic crisis. Frequently the posterior dislocations are misunderstood, so they become chronic lesions. We reported a case of an acute posterior left shoulder dislocation with lesser tuberosity fracture and reverse Hill-Sachs lesions which involved more than 25% of the articular surface of the humeral head, in a 57-old-year man with right hemiparesis. We performed a synthesis of the lesser tuberosity with a screw, and we restored the shape of the humeral head with allograft. We achieved a good result that allows the patient to be able to do his previous activities of daily living.