Complications and institutionalization are almost doubled after second hip fracture surgery in the elderly patient.

PURPOSE: To determine patient and hip fracture characteristics, early postoperative complication rate, and need for institutionalization at the time of discharge from the hospital in patients treated for a second contralateral hip fracture. METHODS: During a 6-year period (2003-2009), 71 patients (60 women and 11 men; age range, 54-94 years) underwent first hip fracture surgery and subsequent contralateral hip fracture surgery at our hospital. Variables, including age, gender, American Society of Anesthesiologists classification (ASA), AO fracture classification, time between both hip fractures, rate and severity of early postoperative complications, and destination of discharge were obtained from the electronic medical records. Data from both hospitalization periods were compared. RESULTS: Forty-six percent of second hip fractures occurred within 2 years after the first hip fracture. After the first hip fracture surgery, 13 patients had 1 or multiple complications compared with 23 patients after a second hip fracture surgery (P = 0.02). The mean time (±SD) between the first and second hip fractures in patients without complications after the second injury was 4.3 (±4.2) years, compared with 2.6 (±2.1) years in patients with complications after the second injury (P = 0.03). The mean ASA classification of patients without complications after the second hip fracture surgery was 2.6 (±0.6) versus 3.0 (±0.6) in patients with complications (P = 0.04). After the first hip fracture surgery, 27 patients (38%) were discharged to an institutional care facility, whereas 72% of patients resided at an institutional care facility after a second hip fracture. CONCLUSIONS: Early complication rate in patients sustaining a second contralateral hip fracture was almost twice that documented after the first hip fracture. After the second hip fracture surgery, most patients resided in an institutional care facility. LEVEL OF EVIDENCE: Prognostic level II. See Instructions for Authors for a complete description of levels of evidence.

Treatment of types II-IV endoleaks by injecting biocompatible elastomer (PDMS) in the aneurysm sac: an in vitro study.

PURPOSE: To investigate if an elastomer [polydimethylsiloxane (PDMS)] can be used to effectively treat endoleaks after endovascular aneurysm repair. METHODS: A latex aneurysm (36-mm inner diameter sac, 15-mm inner diameter neck) was attached to an in vitro circulation model. The aneurysm was excluded from the circulation by placing an unstented polyester graft. Endoleak types II-IV were created using different setups. While the circulation setup running, the aneurysm was filled with contrast medium and then the biocompatible PDMS elastomer was injected to exclude the endoleaks and the perigraft area. The sac was considered full when all contrast was pushed out of the sac and the elastomer flowed into the proximal efferent lumbar artery. Treatment was successful when the aneurysm was free of endoleak after control angiography. RESULTS: The endoleaks were created successfully in the latex aneurysm models, with contrast present in the sac before "treatment." After elastomer sac filling, all endoleaks were successfully excluded on angiography; there was no leakage of contrast outside the graft lumen in any of the setups. With the type III endoleak, the disruption in the graft material was sealed by the elastomer, while the entire porous graft was encased in elastomer in the type IV endoleak setup. There was no elastomer within the graft lumen in either case. CONCLUSIONS: This concept of filling the aneurysm sac with PDMS may lead to a percutaneous treatment for endoleaks. While the results of this study show that PDMS may be used to treat endoleaks in vitro, further tests are required to determine if this approach is suitable in vivo.

The upside down Gore Excluder contralateral leg without extracorporeal predeployment for aortic or iliac aneurysm exclusion.

Endovascular techniques, including branched devices to preserve the internal iliac artery are evolving rapidly, but in cases in which the diameter of the proximal sealing zone is larger than that of the distal sealing zone, a reversed tapered device is needed. We describe the off label use of the Gore Excluder contralateral leg endoprosthesis in an upside down configuration to accommodate this diameter mismatch. The preinsertion technical steps of stent graft preparation, which do not require extracorporeal predeployment, are described in detail. As such, an aneurysm of the internal iliac artery and a saccular abdominal aortic aneurysm were successfully excluded.

A retrospective analysis of bilateral fractures over sixteen years: localisation and variation in treatment of second hip fractures.

The aim of this study was the evaluation of contralateral hip fractures after a previous hip fracture. For this retrospective analysis patients were selected from the database of the LUMC, a teaching hospital in the south-west of the Netherlands. We analyzed all patients with a second fracture of a hip between 1992 and 2007. The exclusion criteria were high impact trauma and patients with diseases or medication known to have a negative effect on bone metabolism. A total of 1,604 hip fractures were identified. The possible predictive factors for the second fracture and descriptive statistics related to surgery (Hb and HT before and after the operation, total amount of intra- and postoperative blood loss, type of osteosynthesis, complications, time of death after the last fracture, time between arrival in the hospital and operation and hospital stay for both fractures) were recorded. A total of 32 second hip fractures were identified (2%) at a mean of 27.5 (SD 28.9) months after the initial hip fracture. The mean age at the first fracture was 77.2 years (SD 11.7), and 27 of 32 patients were female. Of these 32 patients (64 bilateral hip fractures), 32 fractures were intracapsular (1 femoral neck, 31 subcapital) and 32 were extracapsular fractures (6 subtrochanteric, 26 transtrochanteric). Although 24 of the 32 patients had identical first and second hip fractures, only eight out of 32 hips were treated with the same implants. There was a significant difference in Singh index between both hips at the time of the first fracture. There was also a significant difference in Singh index between the hip which was not fractured compared with its subsequent index when it was broken. All other studied patient and fracture characteristics were not significantly different. In this population the percentage of second hip fractures was relatively low compared to other studies. The choice of implants in this study shows that implants were chosen randomly. Because there is a significant difference in the Singh index during first and second hip fracture, osteoporosis medication might help reduce the incidence of second hip fractures.

Aortic customize: a new alternative endovascular approach to aortic aneurysm repair using injectable biocompatible elastomer. An in vitro study.

PURPOSE: Aortic Customize is a new concept for endovascular aortic aneurysm repair in which a non polymerized elastomer is injected to fill the aneurysm sac around a balloon catheter. The aim of this in vitro study was to investigate the extent of aneurysm wall stress reduction by the presence of a noncompliant elastomer cuff. METHODS: A thin-walled latex aneurysm (inner radius sac 18 mm, inner radius neck 8 mm), equipped with 12 tantalum markers, was attached to an in vitro circulation model. Fluoroscopic roentgenographic stereo photogrammetric analysis (FRSA) was used to measure marker movement during six cardiac cycles. The radius of three circles drawn through the markers was measured before and after sac filling. Wall movement was measured at different systemic pressures. Wall stress was calculated from the measured radius (sigma = pr/2t). RESULTS: The calculated wall stress was 7.5-15.6 N/cm(2) before sac filling and was diminished to 0.43-1.1 N/cm(2) after sac filling. Before sac filling, there was a clear increase (P < .001) in radius of the proximal (range, 7.9%-33.5%), middle (range, 3.3%-25.2%), and distal (range, 10.5%-184.3%) rings with increasing systemic pressure. After sac filling with the elastomer, there remained a small, significant (P < .001) increase in the radius of the circles (ranges: 6.8%-8.8%; 0.7%-1.1%; 5.3%-6.7%). The sac filling reduced the extent of radius increase. The treated aneurysm withstood systemic pressures up to 220/140 mm Hg without noticeable wall movement. After the sac filling, there was no pulsation visible in the aneurysm wall. CONCLUSIONS: Filling the aneurysm sac of a simplified in vitro latex model with a biocompatible elastomer leads to successful exclusion of the aneurysm sac from the circulation. Wall movement and calculated wall stress are diminished noticeably by the injection of biocompatible elastomer.

The effect of injectable biocompatible elastomer (PDMS) on the strength of the proximal fixation of endovascular aneurysm repair grafts: an in vitro study.

PURPOSE: One of the major concerns in the long-term success of endovascular aneurysm repair (EVAR) is stent graft migration, which can cause type I endoleak and even aneurysm rupture. Fixation depends on the mechanical forces between the graft and both the aortic neck and the blood flow. Therefore, there are anatomical restrictions for EVAR, such as short and angulated necks. To improve the fixation of EVAR grafts, elastomer (PDMS) can be injected in the aneurysm sac. The support given by the elastomer might prevent dislocation and migration of the graft. The aim of this study was to measure the influence of an injectable biocompatible elastomer on the fixation strength of different EVAR grafts in an in vitro model. METHODS: The proximal part of three different stent grafts was inserted in a bovine artery with an attached latex aneurysm. The graft was connected to a tensile testing machine, applying force to the proximal fixation, while the artery with the aneurysm was fixated to the setup. The force to obtain graft dislodgement (DF) from the aorta was recorded in Newtons (N). Three different proximal seal lengths (5, 10, and 15 mm) were evaluated. The experiments were repeated after the space between the graft and the latex aneurysm was filled with the elastomer. Independent sample ttests were used for the comparison between the DF before and after elastomer treatment for each seal length. RESULTS: The mean DF (mean +/- SD) of all grafts without elastomer sac filling for a proximal seal length of 5, 10, and 15 mm were respectively, 4.4 +/- 3.1 N, 12.2 +/- 10.6 N, and 15.1 +/- 6.9 N. After elastomer sac filling, the dislodgement forces increased significantly (P < .001) to 20.9 +/- 3.8 N, 31.8 +/- 9.8 N, and 36.0 +/- 14.1 N, respectively. CONCLUSIONS: The present study shows that aneurysm sac filling may have a role as an adjuvant procedure to the present EVAR technique. The strength of the proximal fixation of three different stent grafts increases significantly in this in vitro setting. Further in vivo research must be done to see if this could facilitate the treatment of aneurysms with short infrarenal necks.

Minor influence of humeral component size on torsional stiffness of the Souter-Strathclyde total elbow prosthesis.

The use of Souter-Strathclyde total elbow prostheses is a well-studied replacement therapy for reconstruction of the elbow, but loosening of the humeral component is still of concern at long-term follow-up. In this study we looked at the effect of humeral component size and bone mineral density with respect to the bone size, torsional stiffness and torque to failure in cadaveric bones. Fourteen cadaveric humeri were available for testing purposes and four different humeral component size categories were used. First, we calculated the bone quality using dual-energy X-ray absorptiometry (DEXA). The torsional stiffness of the prosthetic humeri was measured during two mechanical tests: Firstly, the applied torque was recorded during a torsion fatigue test. The change of torsional stiffness between the tenth and last cycle was calculated. Secondly, a simple torsion test was performed and the torque to failure was recorded. No significant differences in outcome were seen between sizes of humeral components, even after correction for the bone size. Torsional stiffness and torque to failure were significantly correlated with bone mineral density and not with component size. In conclusion, bone quality seems to be a major eminent factor in the fixation of the humeral component in elbow replacement surgery.

Pre-transplant blood transfusion and cyclosporin A induce long-term hamster cardiac xenograft survival in immunocompetent rats.

BACKGROUND: In previous studies we have shown that pre-transplant hamster blood transfusion (HBT) can induce non-responsiveness in the T cell independent immunecompartment and result in tolerance towards hamster cardiac xenografts (Xgs) in T cell deficient athymic nude rats. In this study we test the combination of pre-transplant HBT with cyclosporin A (CSA) in immunocompetent Lewis rats. METHODS: Before transplantation of a hamster cardiac Xg, 1 ml hamster blood was administered to nude rats or Lewis rats. CSA dissolved in olive oil was given orally at varying doses. Anti-hamster antibodies were measured by flowcytometry. RESULTS: In nude rats HBT 3 days before transplantation resulted in 100% long-term survival >100 days (n=9). In Lewis rats, HBT resulted in hyperacute rejection (HAR) (n=6). Treatment of nude rats with CSA at doses varying from five to 20 mg/kg/day and treatment of Lewis rats with CSA five or 10 mg/kg/day did not effect Xg survival. However, treatment of Lewis rats with CSA 20 mg/kg/day led to long-term survival of five of nine Xgs (p <0.01). Combination of HBT with CSA 10 mg/kg/day in Lewis rats resulted in long-term survival of four of seven Xgs. HBT and CSA 20 mg/kg/day resulted in 100% long-term survival (n=9). Immunoglobulin M (IgM) increased after HBT and CSA in these Lewis rats, but decreased after transplantation and remained low over time. When CSA was discontinued, IgM increased and Xgs were rejected (n=3). CONCLUSIONS: This study confirms that pre-transplant HBT results in long-term survival of hamster cardiac Xgs in nude rats. HBT and CSA have strong synergistic effects in immunocompetent Lewis rats. Combination of HBT with CSA treatment leads to long-term Xg survival in Lewis rats, whereas HBT alone results in HAR. The presence of T cells has a dominant influence on Xg survival after pre-transplant blood transfusion.

Mortality after peripheral bypass surgery: value of a mortality scoring system in evaluating the quality of care.

The objective of this study was to determine the role of a mortality registration in the quality control of patients who died after peripheral bypass surgery. We developed a mortality registration to classify causes of death, to evaluate shortcomings in treatment, and to determine the extent of agreement between pre- and postmortem findings. In a 10-year period, 28 of the 1,022 patients (2.7%) who underwent peripheral arterial reconstruction died. Fifty-three percent of the patients died owing to postoperative complications, most frequently a myocardial infarction. A shortcoming in the medical treatment was observed in only one patient. Forty-three percent of the relatives gave permission for an autopsy. In only two cases, the autopsy report revealed a myocardial infarction that had remained unnoticed during the clinical course. In this selected group of patients undergoing a peripheral bypass operation, the causes of death and the shortcomings in medical care could usually be identified without the help of autopsy data.