Serum lactate as a marker of mortality in patients with hip fracture: A prospective study.

Outcomes from patients suffering hip fracture remain poor, with 9% mortality at 30 days and 35% at 1 year. Despite robust guidelines these mortality rates have undergone little change. Admission serum lactate in patients with sepsis or suffering general trauma has been shown to be an indicator of adverse clinical outcomes. We investigated whether venous lactate can predict mortality for hip fracture patients. Over a 12-month period the admission venous lactate of all patients presenting to our institution with hip fractures was prospectively collated. Demographic and patient survivorship data were also prospectively recorded. Multivariate binary logistic regression and Cox proportional hazards ratio analysis was used to evaluate the relationship between admission venous lactate and 30-day mortality and early survivorship, whilst adjusting for age and gender. 770 patients were included in the study. The mean age was 80 years. The overall 30-day mortality for this cohort was 9.5%. Admission venous lactate was associated with early death. A 1mmol/L increase in venous lactate resulted in a 1.9 (95% CI 1.5-2.3 p<0.0001) fold increase in the odds of 30-day mortality and a 1.4 (95% CI: 1.2-1.6 p<0.0001) factor increase in the risk of death at any time after hip fracture. Admission venous lactate remained a predictor of mortality despite adjustment for patients American Society of Anesthesiologists (ASA) grade. Those with an admission serum lactate of 3mmol/L or greater were particularly at risk. This cohort had a 30-day mortality odds that was 5-fold higher than those whose level was less than 3mmol/L (p<0.0001) and at any-time risk of death that was 1.9 times higher (p<0.0001). Those with a level of less than 3mmol/L had a 30-day mortality of 6.8%. For those with an admission venous lactate of 3mmol/L or greater this was four times higher at 28%. The difference was statistically significant (p<0.0001). Elevated admission venous lactate following hip fracture is a predictor of early death. Venous lactate may be useful as a prognostic indicator or risk stratifier in patients with proximal femoral fractures.

Axillary artery injury secondary to displaced proximal humeral fractures: a report of two cases.

We report 2 cases of axillary artery injury secondary to low-energy proximal humeral fractures. In case 1, early diagnosis based on signs of acute ischaemia of the arm enabled early treatment and a favourable outcome. In case 2, there were no signs of ischaemia or neurological deficit, resulting in delayed diagnosis and increased severity of the injury. The patient developed a false aneurysm and sepsis and eventually died. A high index of suspicion is necessary for diagnosing an axillary artery injury. We recommend that all patients with proximal humeral fractures with severe medial displacement of the shaft and a bone spike should routinely undergo Doppler ultrasound scanning to rule out vascular injuries and the presence of a false aneurysm.

Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes.

The aim of the study was to see if delay in anterior cruciate ligament (ACL) reconstruction affects post-reconstruction outcome in recreational athletes. Sixty-two recreational athletes who had arthroscopic ACL reconstructions using quadruple hamstring grafts between 1997 and 2000 were retrospectively evaluated. Patients with less than 2 years' follow-up, those with multi-ligament injuries, reconstructions for previous failed repairs, those whose injury date was unknown, those with pre-injury Tegner activity level greater than 7 (competitive athletes) and those lost to follow-up were all excluded. Forty-six patients (38 males) were entered. The mean follow up was 38 months and the mean time from injury to index ACL reconstruction was 27 months. Apart from two revisions there were no other significant complications. Forty-one (89%) patients were evaluated in a review clinic. There was a significant improvement in the post-reconstruction Lysholm scores and an improvement in the Tegner scores. The Spearman's correlation coefficient between postoperative Lysholm score and the delay until surgery was -0.18 and the correlation coefficient between postoperative Tegner scores and the delay until surgery was 0.14. Thirty-five patients returned to sporting activity. Thirty-seven rated their knee as being normal or nearly normal and 35 said that their knee function was as they had expected it to be. Late ACL reconstruction does not adversely affect the outcome in recreational athletes. ACL reconstruction should be offered to these patients as there is a significant improvement in the knee function and patients are satisfied with the results.

Review of the clinical results of arthroscopic meniscal repair.

A total of 62 arthroscopic meniscal repairs (60 knees in 59 patients) over a 5-year period were evaluated retrospectively to assess outcome and to identify factors that might improve future clinical results. The overall success rate was 66.1%. Early repair within 3 months of sustaining the tear gave better results (91%) than if carried out later (58%). Suture repair alone yielded better results (78%) than meniscal arrows or a T-fix device (56%). Healing rates of atraumatic meniscus tears were much lower than for traumatic tears (42 vs. 73%). The isolated atraumatic medial meniscal tear appeared to do particularly poorly (33% healing) and may be better treated by meniscectomy.

Acute compartment syndrome of the thigh after weight training.

Compartment syndrome of the thigh is a rare but serious condition that is normally associated with closed trauma or compressive injury. A case of acute compartment syndrome of the thigh occurred in a 16 year old boy after intensive weight training. There was no evidence of muscle tear or focal haemorrhage during subsequent fasciotomy.

A comparative study of early motion and immediate plaster splintage after internal fixation of unstable fractures of the ankle.

We reviewed 47 patients following operatively treated ankle fracture-dislocation, at an average of 15 months after injury, to assess the outcome of two different postoperative regimens. Of the 47 patients, 27 received early active and passive ankle exercises, and 20 patients received immediate plaster splintage. Patients were assessed clinically by an independent surgeon and subjective, objective and radiological criteria recorded. No significant difference was apparent between the two groups on any of the criteria, although the early movement group contained more patients who were completely pain free, had a normal gait and no radiological signs of arthrosis (P < 0.05). This was achieved at the expense of a longer stay in hospital (average 10.2 days versus 7.4 days for plaster splintage) and more ankle swelling.

Cemented versus uncemented femoral components in the ring hip prosthesis.

A prospective, randomised and independently assessed trial of the Ring UPM total hip replacement showed that the quality of the early result was better if the femoral prosthesis was cemented than if it was not. More patients with cemented prostheses were painfree at four months (58% cemented:42% uncemented) and at one year (63% cemented:50% uncemented), but at two years pain relief was equal in both groups. At two years significantly more patients with cemented prostheses could walk without support (96% cemented:62% uncemented, p = 0.01 to 0.05). There is a need for more similar trials to compare the results of contemporary designs of cemented and uncemented total hip prostheses.