Acute confusional state in the elderly following hip surgery: incidence, risk factors and complications.

OBJECTIVE: To determine incidence and risk factors for the development of postoperative acute confusional state (ACS) in the elderly. DESIGN: A prospective cohort study. SETTING: University hospital. PATIENTS: One hundred and five consecutive patients without ACS at baseline who underwent hip surgery because of hip fracture or elective hip replacement. All patients were 60 years or older. MEASUREMENTS: All patients underwent preoperative and daily postoperative evaluation by a research psychiatrist. Standardized instruments were used for cognitive screening, baseline assessment of depression, screening for alcohol abuse, comorbidity, and functional status. ACS was diagnosed by using the Confusion Assessment Method (CAM). Additional medical data were taken from patients' charts and anaesthetic records. RESULTS: Postoperative ACS developed in 23.8% of the study sample, in 40.5% of the hip fracture group and in 14.7% of the hip joint replacement group. The prevalence was highest between postoperative days 2 and 5. Multiple logistic regression analysis demonstrated the following risk factors of ACS: higher age (OR = 1.14, 95% CI 1.07-1.22), prior cognitive impairment as measured by Mini-Mental State Examination (OR = 1.32 for each point less, 95% CI 1.06-1.64), depression (OR = 3.67, 95% CI 1.12-12.02), low educational level (OR = 3.59, 95% CI 1.14-11.25), and preoperative abnormal sodium (OR = 4.32, 95% CI 1.01-18.38). Other risk factors showing statistically significant differences in the univariate analyses were: living in nursing home, vision or hearing impairment, higher comorbidity, regular use of psychotropic drugs before admission, fracture on admission, preoperative leucocytosis. A considerable proportion of patients with ACS showed self-destructive behaviour postoperatively, whereas self-destructive behaviour was not observed among non-delirious patients. CONCLUSIONS: ACS is common among elderly hip surgery patients. The occurrence of ACS is influenced by several predisposing and precipitating factors. Further knowledge of these risk factors will contribute to the early identification of high risk patients and to the development of preventive measures.

C-reactive protein in patients who had operative fracture treatment.

C-reactive protein as an indicator of infection, may help to detect surgical complications early and provide a better outcome for patients. To obtain a baseline for the use of C-reactive protein, the kinetics of C-reactive protein levels of 330 patients who had operative fracture treatment were studied before and after surgery. All patients who had an uneventful postoperative course had similar evolution in their C-reactive protein values: the peak level, which occurred on the second postoperative day, depended on the region of trauma (femoral fractures, 15.4 mg/dL versus ankle fractures, 3.5 mg/dL) and reflected the extent of surgical trauma. Of 47 patients with complicated courses, C-reactive protein proved helpful as a marker in risk stratification and as an early indicator for infection. Of nine patients with a deep wound infection, a high rise of C-reactive protein was recorded, and seven patients showed a rise in the C-reactive protein level before the onset of clinical symptoms. A cut-off level of 14 mg/dL on the fourth day after surgery was recorded for the patients with deep wound infection.

Fracture healing of the sheep tibia treated using a unilateral external fixator. Comparison of static and dynamic fixation.

It is generally accepted that when a fracture is treated with external fixation, dynamization of the fixation accelerates formation of the bony callus by transferring part of the functional loads. The aim of the research presented here was to validate this principle using in vivo measurements of callus stiffness. We created a transverse fracture in the mid third of the tibial shaft in 12 sheep and maintained a 3 mm gap between the fragments for 3 weeks. Two types of unilateral external fixators were applied. Axial loading was permitted (dynamization) from the fourth week onwards in 6 animals. In the other 6 animals, fixation remained static for both types of fixation. Weekly measurements of callus stiffness were obtained using a goniometer and load cell to assess bending stiffness. Two slightly different fixators were used. Callus formed in all 12 animals. Callus stiffness increased exponentially to reach the degree of stiffness measured on the contralateral side. There was no clear difference in healing between the two types of fixations nor between dynamic and static fixation. If a unilateral fixator was applied which did not maintain absolutely rigid fixation, the fracture generally healed well even without contact between the fragment ends. If the process of callus formation had begun normally, dynamic fixation offered no further benefit. Measuring the stiffness of the callus with an adequate measurement apparatus in vivo indicated that the fixator could be removed earlier than would have been authorized on the basis of radiological evidence alone.

[Glycosaminoglycans as markers of post-traumatic gonarthrosis?]. / Glykosaminoglykane als Marker für die posttraumatische Gonarthrose?

Osteoarthritis (OA) influences the levels of free intraarticular glucosaminoglycans (GAG). Little is known about the direction--decrease/increase--of these changes, and information on the correlation between GAG levels and the degree of OA is sparse. Objectives of this study were to investigate the correlation between intraarticular levels of sulphated and unsulphated GAG and the degree of experimental OA, the time course of these changes and whether GAG might be useful as a marker for OA. Twenty-one sheep were randomly assigned to three groups: (1) transsection of the posterolateral bundle of the anterior cruciate ligament, ACL (TD), (2) medial meniscectomy (ME), and (3) meniscectomy and resection of the ACL (MV). During follow-up clinical and radiological examinations were done. After screening for intraarticular effusions, a joint tab was performed and the levels of hyaluronic acid and chondroitin sulphate were measured. The radiological scores differ significantly between group TD and groups ME and MV (P < 0.01). Hyaluronic acid levels in ME and MV are significantly higher than in the controls. Significantly increased levels (P < 0.01) of chondroitin sulphate are found 6 months after ME and 1 year following TD. Clinical consequences: Hyaluronic acid levels--at least in the experimental setting--correspond to a certain degree with osteoarthrotic changes: increasing levels were found along with increasing postoperative interval and increasing grade of OA. Chondroitin sulphate, on the other hand seems, to lend itself as a marker for chondromalacia, in other words for prearthrotic deformities and early stages of OA.

[A comparison of plain film, axial CT, 2D and 3D reconstructions in unstable spinal injuries following surgery]. / Vergleich von Ubersichtsbild, axialer CT, 2D- und 3D-Rekonstruktion bei instabilen operierten Wirbelsäulenverletzungen.

During a period of 18 months about 70 patients suffering from an unstable spinal injury were operated in the surgical department of our clinic. In 50 of these patients it was possible to correlate the results of preoperative radiography and CT with the operative findings. Several cases of distraction instability in the dorsal column had not been recognised in the preoperative radiologic evaluation. Therefore the rationale of this study was the question as to whether modern CT technology can help to avoid such wrong diagnoses. For that purpose radiographs, axial CT-scans of 2 mm thickness or less, sagittal and coronal 2D and (in 35 cases) 3D reconstructions were re-evaluated step by step by a specifically trained radiologist without knowing the operative findings. 15 additional lesions out of 28 were demonstrated and specifically classified as distraction instabilities of the dorsal column using the improved CT technology.

[Primary management of fresh injuries of the thoracic and lumbar vertebrae]. / Die primäre Versorgung der frischen Verletzungen von Brust- und Lendenwirbelsäule.

Results of conservative treatment of vertebral body fractures and of repositioning and internal fixation, are compared with those obtained by dorsoventral repositioning and fusion. The results achieved with patients treated by dorsoventral fusion were statistically significantly better than those obtained with the other two treatment methods. Consequently, we modified the treatment concept of thoracic and lumbar vertebral body fractures. Every vertebral disk showing irreversible damage is now resected and the mobility segment involved is fused. The fracture is treated conservatively only in case MR does not reveal any lesion of the vertebral disk, or it is stabilised only from the dorsal approach.

[Validity of nuclear magnetic resonance tomography in evaluation of the traumatized intervertebral disk]. / Die Validität der Kernspintomographie bei der Beurteilung der traumatisierten Bandscheibe.

The validity of the magnetic resonance imaging (MRI) in the diagnosis of injured intervertebral discs was examined by a prospective diagnostic study. The golden standard being intraoperative discography. The examinations were carried out on both intervertebral discs adjoining the fractured vertebral body. There were 27 patients with 54 injured discs. The sensitivity of the MRI as a noninvasive method is 96%, the specificity is 75%. These results comply with a validity of 88%.

[NMR tomography compared to skeletal scintigraphy after traumatic vertebral body fractures]. / Die Kernspintomographie im Vergleich zur Skelettszintigraphie nach traumatischen Wirbelkörperfrakturen.

MRI and scintigraphy were compared in 73 patients with 104 vertebral fractures aged between three days and 64 months. MRI was performed at 0.5 Tesla and 1.5 Tesla using T1- and T2-weighted spin-echo sequences. Isotope uptake was divided into four grades (normal, mild, moderate and marked increase). 92% of cases aged 0-6 months showed increased signal intensity on T2 sequences. This finding reflects edema in the bone. All these cases showed moderate or markedly increased uptake in 86%. The increased signal intensity in T2 spin-echo images provides a criterion for differentiating new from old fractures. The identification of normal fatty marrow in 91% of fractured vertebrae provides an important means for distinguishing traumatic from neoplastic fractures. One can also demonstrate bleeding, fatty change and sclerotic bone. MRI is less sensitive than scintigraphy, but more specific in following the posttraumatic healing process.

[Surgical treatment of primary and secondary malignant tumors of the thoracic and lumbar spine]. / Operative Therapie von primären und sekundären malignen Tumoren von BWS und LWS.

After considering conservative therapeutic measures, the authors opt for surgical treatment of primary or secondary spinal tumors if neurologic deficits occur or the structural stability of the spine is at risk. The majority of the tumors are located in the ventral section of the spine, i.e., in the vertebral body, and therefore the present authors mainly perform ventral tumor resection and spinal reconstruction (traction implant plus bone cement and ventral traction bracing with the DKS system). In cases with tumor spread over several segments and/or lumbosacral involvement the authors recommend combined ventral and dorsal procedures in order to achieve adequate stability of the vertebral body prosthesis.

[Conservative fracture treatment of the cervical spine with halo fixation]. / Die konservative Frakturenbehandlung der Halswirbelsäule mit dem Halo-Fixateur.

A differentiated therapeutic approach is necessary in discoligamentous or osseous lesions of the cervical spine. Whereas lesions with neurological disturbances are stabilised by operation almost in all cases--and extensive lesions of the lower cervical spine (C3 to C7) quite frequently--, conservative treatment is the order of the day in sequels to trauma at the upper cervical spine (C1 and C2) as well as in mild lesions of all sections of the cervical vertebral column. Fractures of the dens of Types II and III (after Anderson and d'Alonzo) are the exception, since they are now being stabilized by surgery on a large scale. The advantages of the halo-fixateur therapy compared against extension and immobilization in Minerva gypsum are that secondary correction of positioning is possible; that functionally disturbing and extended spondylodeses are avoided; that care of the polytraumatized patient is facilitated; that X-ray films are easy to assess; and that the period of hospitalization is greatly reduced. Successful treatment is possible only of the possible complications are known. Failures are possible if the head screws become loose, if there are pin-trac infections, if dislocations and fractures are redislocated, and if there are points of pressure beneath the jacket.

[Selective arterial DSA of the femur head vessels]. / Die selektive arterielle DSA der Hüftkopfgefässe.

Selective arterial DSA of the arteries of the femoral head was carried out in 39 patients. The appearances were studied in nine patients without any hip abnormality, in 13 idiopathic and eight post-traumatic cases of femoral head necrosis and in nine patients with recent fractures. In every patient the vessels were well demonstrated. In the presence of idiopathic aseptic necrosis there was always hypervascularity around the necrotic area. As in the normal controls, pathological findings were seen in the deep branch of the medial circumflex femoral artery and in the nutrient artery in one-third of patients. Post-traumatic aseptic necrosis, recent fractures and dislocations always showed abnormalities of the vessels to the femoral head. The changes in the femoral head vessels demonstrated by DSA are probably not of great significance for the development of idiopathic aseptic necrosis, however they are found regularly following trauma.

[Bilateral shoulder dislocation fractures, femoral neck and vertebral fractures: a remarkable combination of injuries during an epileptic seizure]. / Bilaterale Schulter-luxationsfrakturen, Schenkelhals- und Wirbelfraktur: Eine bemerkenswerte Verletzungskombination im epileptischen Anfall.

Fracture complications of convulsions are reported occasionally, e.g.: mono- or bilateral posterior shoulder luxations and luxation fractures, central dislocations of the hip as well as fractures of the femoral neck or compression fractures of vertebrae. A case is reported where the patient sustained four such lesions simultaneously. The epileptic seizure occurred following the sudden interruption of a neurotropic therapy with Carbamazepin (Tegretal). A general osteodystrophy was not found. The simultaneous presence of four such lesions following one convulsion has never before been reported and appears to be very uncommon. The frequency and problems of post-epileptic fractures are discussed and the operative treatment of the lesions briefly described.

[Does Osgood-Schlatter disease modify the position of the patella?]. / Beeinflusst der M. Osgood-Schlatter die Position der Patella?

The Blackburne and Peel method of assessing the position of the patella was applied to 185 knees with Osgood-Schlatter disease in 125 patients. The normal index of 0.80 was confirmed in 73 controlled knees. The average index in the knees with Osgood-Schlatter disease measured 1.01 (patella alta) in boys and 0.91 (normal) in girls. The value increased to 1.06 in boys with radiological evidence of loose ossicls in the tibial tuberosity or the patellar tendon. This finding indicates that the strong pull of the well developed quadriceps muscle in probably the most important aetiological factor in the patella alta associated with Osgood-Schlatter disease.

[Computed tomography of chondrogenic tumors]. / Computertomographie bei chondrogenen Tumoren.

The computed tomography (CT) morphology of chondrogenic tumors and the utility of CT in their diagnostic work-up is presented on the basis of 19 cases. CT provided unique informations regarding definition of tumor extent and tumor relationship to adjacent structures particularly in the axial skeleton. CT has diminished the indications for angiography in chondrogenic tumors.