Diagnosis and therapy of osteoporosis in geriatric trauma patients: an update.

Demographic changes confront clinicians with an increasing number of orthogeriatric patients. These patients present with comorbidities, which force their surgeons to take into consideration their medical condition. A major risk factor for fractures in orthogeriatric patients is osteoporosis in combination with frailty. To prevent subsequent fractures in these patients, we need to pay attention to adequate osteoporosis treatment in orthogeriatric patients. There is a huge treatment gap. In Germany, 77% of patients with osteoporosis are not treated adequately. Even after fragility fractures, a low percentage of patients receive a specific osteoporosis therapy. Secondary prevention is of great importance in the treatment of these patients. Diagnostics and treatment should be already initiated with the admission to the hospital. Treatment decisions need to be made individually based on the risk profile of the patients. After discharge, it is important to involve the patients' general practitioners and to follow up on patients regularly to improve their compliance and to ensure adequate therapy. Establishing a fracture liaison service helps coordinating osteoporosis treatment during hospitalization and after discharge. Subsequent fractures can be reduced; therefore, it is an effective service for secondary prevention. The present article provides an overview of how an efficient identification and subsequent treatment of osteoporosis can be achieved in aged trauma patients.

A prospective study of growth and rupture risk of small-to-moderate size ascending aortic aneurysms.

OBJECTIVE: The natural history of small-to-moderate size ascending aortic aneurysms is poorly understood. To follow these patients better, we have developed a method to objectively and reproducibly measure ascending aortic volume on the basis of gated contrast computed tomography scans. METHODS: From 2009 to 2011, 507 patients were referred for management of ascending aortic aneurysms. A total of 232 patients (46%) with small-to-moderate size aneurysms who did not have compelling indications for operation had measurement(s) of ascending aortic and total aortic volume; 166 patients had more than 1 scan, allowing measurement of growth. A total of 66 patients admitted to the emergency department without ascending aortic pathology served as a reference group. RESULTS: None of the patients experienced rupture, dissection, or death; 3 patients ultimately underwent operation. Ascending aortic volume and volume/total aortic volume differed for the surveillance and reference groups: 132.8 ± 39.4 mL versus 78.0 ± 24.5 mL; 38.3% ± 7.4% versus 29.1% ± 3.9%, respectively (both P < .001). Diameters at the sinotubular junction and mid-ascending aortic were 4.1 ± 0.6 cm and 4.4 ± 0.6 cm, respectively, for the surveillance group and 3.0 ± 0.4 cm and 3.2 ± 0.4 cm, respectively, for controls. The increase in ascending aortic volume was 0.95 ± 4.5 mL/year and 0.73% ± 3.7%/year (P = .007 and .012, respectively). Analysis of risk factors for ascending aortic growth revealed only the use of antithrombotic medication as possibly significant. CONCLUSIONS: Computed tomography volume measurements provide an objective method for ascertaining aortic size and monitoring expansion. Patients with small-to-moderate ascending aortic aneurysms who are carefully followed and managed appropriately have slow aneurysm growth and a small risk of rupture or dissection. Annual computed tomography screening may not be indicated, and elective resection-absent other surgical indications-is not necessary. The rupture/dissection risk for even larger aneurysms in carefully followed patients may be lower than currently believed.

Open repair of descending and thoracoabdominal aortic aneurysms and dissections in patients aged younger than 60 years: superior to endovascular repair?

BACKGROUND: The best option for repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAA)-whether open operation or stent grafting-is increasingly a subject of controversy. We examined the results of open surgical repair in patients aged 60 years or younger to assess the value of conventional repair in younger patients. METHODS: From October 2002 to October 2010, 107 of 294 TAAA operations were in patients (75 men [70%]) aged a mean of 48 ± 9 years. Twelve patients (11%) had Marfan syndrome. Operations were elective in 101 (94%); previous aortic operations had been performed in 40 (37%). The most common indication for operation was chronic dissection, in 60 (56%); 5 (4.7%) had acute dissection, and rupture was present in 6 (5.6%). Descending repair was undertaken in 44 (41%), in 32 (73%) as an elephant trunk stage II. Deep hypothermic circulatory arrest was used in 46 (42.9%). Neurologic monitoring and cerebrospinal fluid drainage were routine. Median postoperative follow-up was 4.3 years (range, 2 days to 7.9 years). RESULTS: Overall 30-day mortality was 4.7%. Stroke occurred in 4 patients (3.7%) and paraplegia in 1 (0.9%). The linearized rate for reoperation for TAAA was 0.22/100 patient-years (1 patient in 448.8 patient-years). Survival at 1, 5, and 8 years was 90.5%, 89.4% and 80.5%, respectively. During follow-up, 1 patient with Ehlers-Danlos died of aortic complications at 4.5 years. CONCLUSIONS: Although direct comparison with stent grafting is limited by the diversity of patients and indications in published reports, our results suggest that open repair should be the modality of choice. Early mortality and neurologic complication rates are similar, if not superior, to endovascular repair for descending aortic and TAAAs. Open repair has proven durability and a very low rate of required reintervention, in contrast with endovascular repair.

Imaging of vascular remodeling after simulated thoracoabdominal aneurysm repair.

OBJECTIVE: A better understanding of the response of the spinal cord blood supply to segmental artery (SA) sacrifice should help minimize the risk of paraplegia after both open and endovascular repair of thoracoabdominal aortic (TAA) aneurysms. METHODS: Twelve female juvenile Yorkshire pigs were randomized into 3 groups and perfused with a barium-latex solution. Pigs in group 1 (control) had infusion without previous intervention. Pigs in group 2 were infused 48 hours after ligation of all SAs (T4-L5) and those in group 3 at 120 hours after ligation. Postmortem computed tomographic scanning of the entire pig enabled overall comparisons and measurement of vessel diameters in the spinal cord circulation. RESULTS: We ligated 14.5 ± 0.8 SAs: all filled retrograde to the ligature. Paraplegia occurred in 38% of operated pigs. A significant increase in the mean diameter of the anterior spinal artery (ASA) was evident after SA sacrifice (P < .0001 for 48 hours and 120 hours). The internal thoracic and intercostal arteries also increased in diameter. Quantitative assessment showed an increase in vessel density 48 hours after ligation of SAs, reflected by an obvious increase in small collateral vessels seen on 3-dimensional reconstructions of computed tomographic scans at 120 hours. CONCLUSIONS: Remodeling of the spinal cord blood supply--including dilatation of the ASA and proliferation of small collateral vessels--is evident at 48 and 120 hours after extensive SA sacrifice. It is likely that exploitation of this process will prove valuable in the quest to eliminate paraplegia after TAA aneurysm repair.

Frequency of reoperations in patients with Marfan syndrome.

BACKGROUND: We undertook a retrospective study of the pattern of reoperations in surgical patients with Marfan disease. METHODS: Between 1985 and 2008, 83 Marfan patients (60 males, 23 females) underwent 155 aortic operations in our institution. Twenty-eight patients had acute dissection (22 type A, 6 type B), and two had aortic rupture. Mean age at initial operation was 32±13 years. Operations included valve-sparing or Bentall aortic root repair, and ascending aorta, arch, descending thoracic, thoracoabdominal aorta, and infrarenal aortic replacement. Sixty-one patients whose initial operation was elective (Group I) were compared with 22 patients with initial emergency surgery (Group II). RESULTS: Overall, 81/83 patients ultimately underwent root/ascending repair: 64% initially and 36% at reoperation. Operative mortality in Group I was 1.6% for both initial operations and reoperations vs 9.0% and 0% in Group II. Significant differences between Group I and Group II patients included: total reoperations (1 vs 3, p=0.05); arch operations (0 vs 1, p=0.003); descending thoracic aortic operations (0 vs 0.5, p=0.003); and total aortic segments replaced (1.6±1.0 vs 2.4±1.1, p=0.001). Survival at 5 and 10 years did not differ between Group I and II patients (87% and 71% vs 82% and 56%, p=0.19). CONCLUSIONS: Although reoperation occurs in about half of surgical Marfan patients, reoperative mortality is low. Patients with initial elective procedures fare better than those with initial emergency surgery: they have fewer subsequent operations, fewer aortic segments replaced, and trend toward improved survival. Elective root replacement should be seriously considered in any Marfan patient with significant root dilatation.