Stability of extracapsular hip fracture: Does it affect rehabilitation outcome of post-acute patients?

BackgroundVarious factors have been shown to affect rehabilitation outcome of hip fractured patients. The degree of extracapsular fracture stability may also affect functional recovery. The aim of our study was to assess the relationship between extracapsular hip fracture stability and rehabilitation outcome in a post-acute setting.MethodsA retrospective cohort study of 144 hip fractured patients was carried out in a post-acute geriatric rehabilitation center from 1/2014 to 6/2015. The main outcome measures were the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM and length of stay (LOS). The associations between patients with stable vs. unstable and clinical, demographic and comorbidity variables, were assessed by the Mann-Whitney U and chi-square tests. A multiple linear regression model was used to estimate the association between fracture stability and LOS score after controlling for sociodemographic characteristics and chronic diseases.ResultsRehabilitation outcomes (FIM and mFIM score changes, mFIM MRFS) were found independent of extracapsular hip fracture stability. Patients with an unstable fracture presented with a significantly longer LOS compared with a stable fracture (p = .008). Multiple linear regression analysis showed that fracture stability was significantly associated with LOS after adjustment for confounding demographic, clinical and functional variables (p = .009).ConclusionPatients with unstable extracapsular hip fractures may require a prolonged rehabilitation period in order to achieve the same functional gain as patients with stable fractures.     

Does pneumatic dilatation affect the outcome of laparoscopic cardiomyotomy?

BACKGROUND: Controversy surrounds the choice of laparoscopic cardiomyotomy as the primary treatment for achalasia or a second-line treatment following the failure of nonsurgical treatment. Laparoscopic cardiomyotomy can be more difficult technically following pneumatic dilatations. The aim of this study was to compare the outcome obtained with primary laparoscopic cardiomyotomy to that achieved when the procedure is performed following failed pneumatic dilatation. METHODS: Laparoscopic cardiomyotomy was performed in seven patients following a median of four pneumatic dilatations (group A) and in five patients as their primary treatment (group B). Outcome was measured using manometry, a modified DeMeester symptom scoring system, and a quality-of-life questionnaire. RESULTS: There were no significant differences between groups A and B in sex, age, preoperative modified DeMeester score, or mean barrier pressure. Six of seven group A patients had evidence of periesophageal and submucosal fibrosis at surgery, but this condition was not seen in group B patients. The operative time was slightly longer in group A patients. There was no difference in complication rates (one primary hemorrhage in group A and one esophageal perforation in group B), and both groups had a significantly improved modified DeMeester score at 6 weeks and at long-term follow-up (median, 26 months). Eleven of 12 patients said that they would choose laparoscopic cardiomyotomy as their primary treatment if newly diagnosed with achalasia. CONCLUSIONS: Laparoscopic cardiomyotomy is safe and effective as a primary or second-line treatment following pneumatic dilatations in patients with achalasia.     

Does the type of biological valve affect patient outcome?

Patient background mortality and excess mortality related to aortic valve disease may play a greater role than implanted valve type in explaining the observed survival differences after aortic valve replacement. This study attempts to identify the differences between the performance of selected biological valves, given similar patient characteristics and excess mortality. Four biological valve types, the Carpentier-Edwards pericardial and supra-annular valve, Medtronic Freestyle valve and allografts were used for this analysis. Primary data calculated observed patient-survival and median time to structural valvular deterioration. We then used a microsimulation model to calculate age-specific patient survival and reoperation- and event-free life expectancies. The model incorporated the US population mortality and a uniform excess mortality, while the hazards of valve-related events after implantation of the four valve types were estimated from corresponding meta-analysis and primary data. Observed 10-year survival (60-69)-year age group survival and median time to SVD for the different valve types did not differ. Microsimulation calculated, for a 65-year-old male for example, a 10-year survival of 51%, 51%, 53% and 56% for Carpentier-Edwards pericardial and Supra-annular valve, Freestyle and allografts, respectively. Patient life expectancy was 10.8, 10.8, 11.0 and 11.4 years, respectively. Assuming uniform patient characteristics and excess mortality, the observed difference in performance between the four biological valve types is less marked. Patient selection and the timing of operation may explain most of the observed differences in prognosis after aortic valve replacement with biological prostheses.     

Does implant selection affect outcome of revision knee arthroplasty?

We reviewed 139 consecutive femoral or tibial revision knee arthroplasties to determine if the outcome of revision knee arthroplasty using revision implant systems was superior to revisions using primary implant systems. Group 1 (n = 42) consisted of revisions performed with implants designed for primary total knee arthroplasty. Group 2 (n = 42) consisted of revisions performed with modified primary components. Group 3 (n = 55) consisted of revisions performed with components specifically designed for revision arthroplasty. The implant status was known in 123 of 139 knees at a mean follow-up of 7 years (range, 5-12 years). The implant-related failure rate, defined as reoperation requiring component revision or removal, was 26% for group 1, 14% for group 2, and 6% for group 3 (P<.05). Revision implants exhibited superior performance and durability despite their use in more difficult reconstructions. The improved longevity of revision implants justifies the evolution of modular revision components.     

Does optimal timing for spine fracture fixation exist?

OBJECTIVE: To evaluate the effect of timing of spine fracture fixation on outcome in multiply injured patients. SUMMARY BACKGROUND DATA: There is little consensus regarding the optimal timing of spine fracture fixation after blunt trauma. Potential advantages of early fixation include earlier patient mobilization and fewer septic complications; disadvantages include compounded complications from associated injuries and inconvenience of surgical scheduling. METHODS: Patients with spine fractures from blunt trauma admitted to an urban level 1 trauma center during a 42-month period who required surgical spine fracture fixation were identified from the registry. Patients were analyzed according to timing of fixation, level of spine injury, and impact of associated injuries (measured by injury severity score). Early fixation was defined as within 3 days of injury, and late fixation was after 3 days. Outcomes analyzed were intensive care unit and hospital stay, ventilator days, pneumonia, survival, and hospital charges. RESULTS: Two hundred ninety-one patients had spine fracture fixation, 142 (49%) early and 149 (51%) late. Patients were clinically similar relative to age, admission blood pressure, injury severity score, and chest abbreviated injury scale score. The intensive care unit stay was shorter for patients with early fixation. The incidence of pneumonia was lower for patients with early fixation. Charges were lower for patients with early fixation. Patients were stratified by level of spine injury. There were 163 cervical (83 early, 80 late), 79 thoracic (30 early, 49 late), and 49 lumbar fractures (29 early, 20 late). There were no differences in injury severity between early and late groups for each fracture site. The most striking differences occurred in the thoracic fracture group. Early fixation was associated with a lower incidence of pneumonia, a shorter intensive care unit stay, fewer ventilator days, and lower charges. High-risk patients had lower pneumonia rates and less hospital resource utilization with early fixation. CONCLUSIONS: Early spine fracture fixation is safely performed in multiply injured patients. Early fixation is preferred in patients with thoracic spine fractures because it allows earlier mobilization and reduces the incidence of pneumonia. Although delaying fixation in the less severely injured may be convenient for scheduling, it increases hospital resource utilization and patient complications.     

Does donor cause of death affect the outcome of lung transplantation?

BACKGROUND: Accumulating evidence suggests that the donor's cause of death may influence posttransplantation allograft function. We conducted a retrospective analysis of our adult lung transplant experience to investigate the influence of donor traumatic brain injury versus nontraumatic brain injury on posttransplantation outcome. METHODS: We retrospectively reviewed donor records and recipient medical charts for 500 consecutive lung transplants performed between July 1988 and December 1999. Recipient follow-up was complete, with a minimum follow-up of 1 year of survival. RESULTS: There were 295 and 205 donors in the traumatic and nontraumatic brain injury groups, respectively. Young male donors predominated in the traumatic brain injury group. Recipients receiving donor lungs from the traumatic and nontraumatic brain injury groups did not differ by age, sex, diagnosis, type of transplant (single-lung versus double-lung) or requirement for pretransplantation mechanical ventilatory assistance. Recipients did not differ in immediate or 24-hour PaO (2)/inspired oxygen ratio, ventilation time, hospital stay, hospital mortality, or overall survival. Recipients of organs from donors who died of traumatic brain injury showed a higher severity and frequency of rejection episodes during the first year after transplantation. Freedoms from bronchiolitis obliterans syndrome at 5 years were 34.5% and 50.8% for recipients of organs from donors who died of traumatic and nontraumatic brain injury, respectively (P =.002). CONCLUSIONS: The cause of donor brain death does not appear to influence early results of lung transplantation. Traumatic brain injury, or some phenomenon associated with it, may predispose a transplanted lung and its recipient toward more severe early rejection episodes and subsequent development of bronchiolitis obliterans syndrome.     

Does appendix position affect the clinical outcome of acute appendicitis?

Objective: To elucidate if the course of acute appendicitis is influenced by the variable positions of the appendix. The appendix positions were divided into two groups: (i) the anterior group, which included the anterior, the pelvic and the paracaecal positions; and (ii) the posterior group, which included the retrocaecal and retroileal positions. Method: The hospital records of 161 patients who underwent appendectomy for acute appendicitis from January 2000 to June 2001 at Prince of Wales Hospital were reviewed retrospectively. Results: Clinicians’ delay in reaching the diagnosis was longer in the posterior group (9.9 h vs 5.8 h; P=0.043). However, complicated appendicitis (gangrenous changes, perforation or abscess formation) was not associated with the appendix location (P = 0.078). The median operating time for laparoscopic appendectomies lasted longer in the posterior group (77.5 min vs 60 min; P = 0.02). These patients also had a longer hospital stay (6 days vs 4 days; P = 0.049). No difference was observed among patients who underwent open surgery. Conclusion: Appendices in the ‘hidden’ position did not translate into a higher incidence of complicated appendicitis or postoperative complications except for the slightly longer hospital stay in patients treated by laparoscopy. Therefore, we concluded that the location of appendices does not affect the clinical course of appendicitis in the locality studied.      

Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome?

Background/Purpose

Continuous epidural analgesia is routinely used to manage pain in infants undergoing resection of a congenital cystic adenomatoid malformation (CCAM) of the lung. Our aim was to determine if there is a difference in the length of stay (LOS), supplemental analgesic requirements, pain control, and the incidence of adverse respiratory events in infants receiving the 2 standard epidural solutions commonly used: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 μg/mL.

Methods

We retrospectively reviewed the charts of infants who received epidural infusions containing bupivacaine 0.1% (n = 18) and bupivacaine 0.1% with fentanyl 2 to 5 μg/mL (n = 10) after CCAM resection during a 12-month period. LOS, rescue opioid, and nonopioid analgesic use, incidence of respiratory depression, and pain scores were recorded.

Results

The LOS in patients receiving fentanyl in their epidural solution was 1 day longer than those receiving plain bupivacaine (median 4 vs 3 days, respectively). Nonopioid analgesic and rescue opioid use was greater in patients who did not have fentanyl in their epidural solutions. Pain ratings were not significantly different. The incidence of respiratory depression was greater in patients receiving epidural infusions containing fentanyl (50% vs 17%, respectively).

Conclusion

The addition of fentanyl to epidural infusions of bupivacaine in infants undergoing thoracotomy for resection of CCAM may prolong recovery and increase the incidence of adverse respiratory events without providing a significant analgesic benefit.     

Does previous open nephrolithotomy affect the outcome of percutaneous nephrolithotomy?

PURPOSE: To determine the effects of previous open nephrolithotomy on the results and morbidity of subsequent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Between March 2005 and January 2006, 89 patients underwent PCNL at our institution. We compared the patients who had had previous open surgery on the same kidney (group 1; n = 27) with those who had had no previous surgery (group 2; n = 62). The two groups did not differ significantly in age (45.4 v 44 years), stone burden (361.3 mm(2) v 482.4 mm(2) ), stone number, or laterality. Operative time, hospital stay, success rate, visual analog pain scores 8 hours after surgery, analgesic doses (diclofenac sodium), and intraoperative and postoperative complications were compared. RESULTS: There were no differences in operating time, postoperative analgesic doses, pain scores, intraoperative and postoperative complications, the number of accesses, or the stone-free rate. CONCLUSIONS: The morbidity and efficacy of PCNL are similar in patients who have had previous open nephrolithotomy and those having no previous surgery. Previous open surgery does not affect the success of PCNL.     

Restorative proctocolectomy. Does ethnicity affect outcome?

Objective  Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is well-established in the management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We review outcome of pouch surgery from a single centre, comparing non-South Asian and South Asian Caucasian populations.
Method  Patients undergoing RPC for UC and FAP during a 10-year period between January 1997 and January 2007 were identified from hospital records. Data were collected retrospectively from case notes on early and long-term results.
Results  A total of 107 patients underwent pouch formation for UC (94%) or FAP (6%) and 22 (21%) were from the Asian subcontinent. Eighty-seven (81%) underwent a three-stage procedure and 20 (19%) a two-stage procedure. Postoperative complications occurred in 40 (37%) patients, being major in 11 (10%) patients with relaparotomy required in 9 (8%) with no difference between South Asian and non-South Asian Caucasian patients. Long-term pouch function, with a median of five times over 24 h (range 2–15), was similar between the two groups. The incidence of pouchitis was 57 (53%) and this was significantly greater in the South Asian population [17/21 (77%); 39/86 (46%); P  = 0.006].
Conclusion  Surgical results were similar in South Asian and non-South Asian Caucasian patients, but the incidence of pouchitis was greater in the former group.