Early Ambulation After Hip Fracture Surgery Is Associated With Decreased 30-Day Mortality.

INTRODUCTION: Hip fractures frequently present in complicated patients and are fraught with high morbidity and mortality rates. Postoperatively, delayed ambulation has been identified as a factor associated with increased mortality, although its magnitude has yet to be quantified. Therefore, this article aims to evaluate mortality after hip fracture surgery because it relates to early postoperative ambulation, taking into account preexisting comorbidity burden. METHODS: This is a retrospective review of patients older than age 65 years who underwent surgical fixation for hip fractures because of a low-energy mechanism. Ambulation during the first 3 postoperative days was recorded along with age and preexisting comorbidity burden (Modified 5-Factor Frailty Index), and 30-day and 1-year mortality statuses were examined. Multivariable logistic regression was used to analyze the association between postoperative ambulation and mortality. RESULTS: Of 485 patients initially identified, 218 met the inclusion criteria. Overall mortality rates were 6.4% at 30 days and 18.8% at 1 year. Two-thirds of patients ambulated in the first 3 postoperative days versus one-third who did not. Patients who did not ambulate had both significantly increased 30-day mortality (odds ratio [OR] 4.42, P = 0.010, 95% confidence intervals [CIs] 1.42 to 13.75) and 1-year mortality (OR 2.26, P = 0.022, 95% CI 1.12 to 4.53). After multivariable logistic regression accounting for age and comorbidity status, ambulation remained strongly associated with 30-day (OR 3.87, P = 0.024, 95% CI 1.20 to 12.50) but not 1-year mortality (OR 1.66, P = 0.176, 95% CI 0.80 to 3.48). Although neither were significant at 30 days, both increasing age (OR 1.05, P = 0.020, 95% CI 1.01 to 1.10) and Modified 5-Factor Frailty Index (OR 1.62, P = 0.005, 95% CI 1.16 to 2.26) correlated with increased mortality at 1 year. CONCLUSION: Early ambulation after hip fracture surgery bears a notable, almost four-fold, association with early postoperative mortality independent of age and medical comorbidities. Our results support a growing body of evidence that ambulation is a powerful tool that should continue to be emphasized to optimize mortality in hip fracture patients.

Open Treatment for Unstable Osteochondritis Dissecans of the Knee: Autologous Bone Grafting and Bioabsorbable Fixation.

Osteochondritis dissecans is a common osteochondral abnormality affecting the knee. In unstable lesions, the underlying bone can be significantly abnormal and necessitate treatment. Although many techniques exist, we favor an open surgical approach to ensure that the bone is properly managed. Autologous bone graft can easily be obtained locally and used to restore the bony architecture. The subsequent use of bioabsorbable implants provides a robust means of fixation that allows for single-stage surgery. This Technical Note describes a straightforward but reliable approach to a challenging pathology.

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

BACKGROUND: Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement. METHODS: Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05). RESULTS: Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement. CONCLUSION: We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.