Prognosis one year after hip fracture

This study evaluates the demography and health in a hip fracture population, and predictors of outcome one year after the fractures occurred. Physical, mental and social functioning in 109 patients who were referred from home with hip fractures were assessed retrospectively; during the hospital stay, at discharge, and after 4 and 12 months. Mobility, Katz' ADL-index and a short-version of MMSE were used in assessing their physical and mental conditions. No essential changes were found in either demography or health. The most significant predictors of outcome were age, prefracture mobility and post-fracture mental status. The proportion of patients suffering from acute confusion was considerable. The result was a higher risk of mortality, institutionalisation and poor physical outcome. It is important to pay more attention to the prevention and treatment of cases involving acute confusion.     

Predictors of mortality after acute hip fracture

To identify determinants of mortality after hip fracture, we performed a multicenter, retrospective study of 390 Medicare beneficiaries. Independent predictors of 30-day mortality included a history of congestive heart failure (odds ratio [OR] 32; 95% confidence interval [CI] 5, 192), angina (OR 26; 95% CI 4, 184), or chronic pulmonary disease (OR 11; 95% CI 2, 62). Postoperative use of aspirin was associated with a reduced risk of mortality (OR 0.24; 95% CI 0.08, 0.70). Cardiovascular events were the presumed cause of 63% of in-hospital deaths. Aspirin may have significant potential to reduce mortality in this population and deserves further study.     

Functional outcome after hip fracture in Japan

One thousand one hundred sixty-nine elderly Japanese patients who sustained a hip fracture were observed prospectively. Ninety-two percent had operative fracture treatment. Hospital length of stay averaged 67 days; 81% of patients were discharged to their place of residence where they resided before sustaining the fracture. Mortality rates at 120 days, 1 year, and 2 years after injury were 6%, 11%, and 19%, respectively. At 1-year followup, ambulatory status was recovered to that of the level experienced before injury in 67% of patients.     

Intracapsular hip pressure after femoral neck fracture

A consecutive series of 34 patients with femoral neck fractures was included in a prospective study aimed at evaluating preoperative variations in intracapsular pressure after changes in hip position, hip traction, and aspiration of hemarthrosis and their influence on the development of femoral head necrosis. Patients were observed for 7 years after surgery. Before aspiration, the mean intracapsular pressure in the antalgic physiologic position was 44.4 mm Hg. There were no differences between displaced and undisplaced fractures. The pressure was a maximum (mean value, 124.8 mm Hg) with the hip in extension and inward rotation, this pressure being greater than the blood systolic pressure in most cases. Hip traction of 3 kg in the antalgic physiologic position was found to be highly effective in preventing any bone flow tamponade effect in displaced and undisplaced femoral neck fractures: the mean intracapsular pressure decreased to 28.5 mm Hg. Aspiration of the hemarthrosis induced a significant decrease in intracapsular pressure only in cases with impaired vascularity of the femoral head as measured by scintigraphy using 99mTc labeled methyldiphosphonate. Aspiration of the hemarthrosis therefore is indicated only in the above cases, although it is less effective than hip traction in the antalgic position. There was no significant correlation between intracapsular pressure and the scintigraphy ratio. Avascular necrosis of the femoral head was detected in six cases. Among these, five patients had an intracapsular pressure below their diastolic blood pressure. This could indicate that vascular damage related to the fracture could be an important cause of bone necrosis despite that blood supply can be decreased by a tamponade effect.     

Predictors of functional recovery after hip fracture in the elderly

Three hundred thirty-eight community dwelling, ambulatory, elderly patients who sustained a hip fracture were observed prospectively to determine which patient and fracture characteristics at hospital admission predicted functional recovery at 3, 6, and 12 months. Multiple logistic regression was performed to estimate the simultaneous contributions of the predictor variables to failure of functional recovery. Before sustaining a fracture, 16% of patients were dependent on basic activities of daily living and 46% were dependent on instrumental activities of daily living. By 1 year after fracture, 73% of the patients had recovered to their basic activities of daily living status before fracture whereas only 48% had recovered to their instrumental activities of daily living status before fracture. Patients who were age 85 years or older, who lived alone before sustaining a fracture, and who had one or more comorbidities were at increased risk of delay or failure in recovering basic activities of daily living. Only instrumental activities of daily living independence before fracture predicted failure to recover instrumental activities of daily living function by 3 and 6 months after fracture. At 1 year, patient age 85 years or older was the only predictor of failure to recover instrumental activities of daily living function that existed before fracture. Based on characteristics at admission, a group of patients at high risk for failure to recover basic activities of daily living function within 1 year of sustaining a hip fracture can be identified.     

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

Traumatic rupture of Dupuytren's contracture is rare. It has been reported only twice in recent times and only on four previous occasions over the last millenium. These cases are reported and the forces involved in rupturing Dupuytren's contracture are discussed.     

Functional recovery and timing of hospital discharge after primary total hip arthroplasty

BACKGROUND: Dental porcelain has found an increased number of applications in recent years with the development of new methods for the construction of porcelain veneers and intracoronal restorations. In addition, it is used in metal-ceramic and all-porcelain crowns and bridges for the restoration of anterior and posterior teeth. METHODS: This paper presents a review of a number of studies that have examined the visual and microscopic appearance and roughness of glazed, unglazed and polished porcelain surfaces using techniques such as, scanning electron microscopy and surface profilometry. FINDINGS: All have agreed that glazed porcelain provides a smooth and dense surface. Many have shown that polishing can produce an equally smooth surface, which may even be esthetically better. Some studies supported the use of polishing as an alternative to glazing. However, reports have shown that unglazed porcelain is more abrasive than glazed. CLINICAL SIGNIFICANCE: This paper aims to guide general practitioners in the proper polishing of adjusted porcelain in the dental office. The recommendations of various authors are summarized in Table I.     

Functional outcome after hip fracture. Effect of general versus regional anesthesia

The effect of anesthetic technique on ambulation and functional recovery after hip fracture was studied in a series of 631 community dwelling, elderly patients. Functional recovery at followup was determined by an 11-item functional rating scale. In univariate analysis, recovery of ambulatory ability and percent functional recovery were significantly higher at 6 months for patients who had general anesthesia. When controlling for potential confounding variables, however, no differences were observed in recovery of ambulatory ability or percent functional recovery between the two groups at 3, 6, or 12 months after hip fracture.     

Bone loss after hip fracture is correlated to the postoperative degree of mobilisation

This study quantifies changes in bone mineral density (BMD) in the opposite hip and in both proximal tibiae and the correlation with the use of walking aids for patients with two types of hip fracture during the 1st year after surgery. In all, 26 women and 15 men aged 42-88 years (median 71 years) were included. Twenty-one patients had an intracapsular hip fracture (ICF) and 20 had an intertrochanteric fracture (ITF). All patients were treated with a dynamic hip screw. BMD was measured by dual X-ray absorptiometry (DXA; LUNAR, Wisconsin) within the 1st week after surgery and after 3, 6 and 12 months. Initial BMD of the non-fractured hip was significantly lower for both fracture groups compared with reference material. For both fracture types there was a significant decrease in BMD of the non-fractured hip and proximal tibia of the fractured leg during the first 3 months, which still persisted a year after surgery. Improved mobilisation between two examinations was positively correlated with changes in BMD of the proximal tibia of the fractured leg and the non-fractured hip.     

Cost analysis for total hip arthroplasty by measurement of time and material expenditure

BACKGROUND AND OBJECTIVES: An estimated 4 million new cases of chlamydial infection occur each year. This experiment assessed the effects of a vaginally applied gel formulation of 0.25% chlorhexidine gluconate on chlamydial infection and on the vaginal ecosystem. STUDY DESIGN: Twelve monkeys were treated with a single application of 0.25% chlorhexidine gluconate. These animals were assessed for changes in vaginal flora before and at 30 minutes, 1 day, and 2 days postapplication by microbiologic analysis. Cervical and vaginal tissues were assessed by colposcopy at each time point. Five monkeys received a single application of 0.25% chlorhexidine gluconate gel followed (30 minutes) by a cervical inoculation with Chlamydia trachomatis. Four monkeys were inoculated with Chlamydia only. Cervicovaginal tissues were assessed via modified colposcopy, vaginal swabs were collected for assessment of vaginal flora, and cervical swabs were collected for detection of Chlamydia (culture/ligase chain reaction) at baseline and days 1, 2, and 7 postinoculation. RESULTS: Changes in vaginal flora were minimal in all monkeys. Application of 0.25% chlorhexidine gluconate did not affect adversely vaginal colonization by lactobacilli. All chlamydial infection control monkeys were infected, whereas none of the five monkeys pretreated with chlorhexidine gluconate were positive for C. trachomatis by culture or ligase chain reaction. Colposcopic observations remained largely unchanged in all groups. CONCLUSIONS: A 0.25% chlorhexidine gluconate gel was protective against chlamydial infection in all animals tested, had no adverse effect on the vaginal flora, and had minimal effect on cervicovaginal tissues after a single application.     

Automated evaluation of hip axis length for predicting hip fracture

The hip axis length has been shown in previous studies to be predictive of hip fracture independent of age and femoral bone density. The first studies of hip axis length were performed by manual measurement of dual x-ray absorptiometry (DXA) scan printouts. In this study, an automated analysis procedure is defined using software tools provided by the DXA manufacturer. Manual and automatic hip axis length measurements in 198 women were highly correlated (r = 0.98). Because of scaling factors of the printout, the automatic measurement was 58% longer than the manual value. Precision of the automatic measurement, based upon triplicate DXA scans of 33 women, was 0.07 cm or 0.68%. To define normative data, the hip axis length was measured from femoral DXA scans of 471 female volunteers aged 40-92 scanned on 14 different Hologic QDR-1000 systems. Mean hip axis length was 10.5 cm, with a standard deviation of 0.62 cm. No significant relationship between hip axis length and age was found (r = 0.07, P = 0.15). Based on previously reported odds ratios corrected for femoral bone density, age, height, and weight, an automatic hip axis length measurement of 11.0 cm is associated with a twofold increase in hip fracture risk compared with a woman with an average hip axis length. A hip axis length value of 11.6 cm increases hip fracture risk by a factor of 4 compared with a woman with a normal hip dimension. We conclude that the hip axis length can be easily incorporated into existing DXA hip analysis software in combination with a bone density measurement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Randomised controlled trial of effects of early discharge after surgery for breast cancer

OBJECTIVE: To determine the effect of early discharge from hospital after surgery for breast cancer on physical and psychological illness. DESIGN: Randomised controlled trial comparing discharge two days after surgery (before removal of drain) with standard management (discharge after removal of drain). SETTING: Regional breast unit. SUBJECTS: 100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80). MAIN OUTCOME MEASURES: Physical illness (infection, seroma formation, shoulder movement) and psychological illness (checklist of concerns, Rotterdam symptom questionnaire, hospital anxiety and depression scale) preoperatively and at one month and three months postoperatively. RESULTS: Women discharged early had greater shoulder movement (odds ratio 0.28 (95% confidence interval 0.08 to 0.95); P = 0.042) and less wound pain (odds ratio 0.28 (0.10 to 0.79); P = 0.016) three months after surgery compared with women given standard management. One month after surgery scores were significantly lower on the Rotterdam symptom questionnaire in patients who were discharged early (ratio of geometric mean scores 0.73 (0.55 to 0.98) P = 0.035), but rates of psychological illness generally did not differ between groups. CONCLUSIONS: Increased rates of physical or psychological illness did not result from early discharge after surgery for breast cancer. This policy can be recommended for patients with support at home.     

Ankle performance after ankle fracture: a randomized study of early mobilization

Low concentrations of some neutral dipeptides, such as L-Ala-L-Ala, rapidly disrupt rat liver lysosomes. The phenomenon has been attributed to an osmotic imbalance generated by the production of amino acids in the lysosome by lysosomal dipeptidase activity. This hypothesis is challenged by testing several pairs of dipeptides available in both D- and L-forms and a range of dipeptides whose susceptibility to lysosomal dipeptidase activity is known. A good correlation was found between the lytic ability of dipeptides and their capacity to cross the lysosome membrane and be hydrolysed by lysosomal dipeptidase. The osmotic-imbalance hypothesis is critically evaluated in the light of the results and of recent information concerning the carrier-mediated transport of amino acids and dipeptides across the lysosome membrane. It is concluded that intralysosomal generation of amino acids remains the most plausible explanation of the lytic activity of dipeptides, and that the dipeptide porter(s) in the lysosome membrane must have higher Km than the amino acid porters.     

The quality circle of hip fracture care

Elderly patients with hip fractures have many medical, physical, and psychosocial challenges. Their care can become complex and require the integration of various disciplines. In this article, the author describes and explains the hip fracture preoperative assessment tool that contains various "red flag" indicators and tools used for data collection. The case manager can use this tool to assess patients before surgery and appropriately plan for discharge. Outcome results are discussed, including functional status, length of stay, and costs.     

Variations in the performance of hip fracture procedures

OBJECTIVE: To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge. DESIGN: Analysis of 1776 admissions to a CCU during a 16-month period. SETTING: The CCU of a major teaching hospital in South Australia. PARTICIPANTS: All patients admitted to the CCU during the 16-month period. OUTCOME MEASURES: CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU). RESULTS: Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05). CONCLUSIONS: In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.     

Estimating the costs of hip fracture and potential savings

Shaker mutant rats are characterized by the adult-onset degeneration of cerebellar anterior lobe Purkinje cells and temporally correlated development of ataxia and tremor. Normal E-13 Purkinje cells were transplanted into the anterior cerebellum in adult shaker mutant rats to study donor/host interactions in an animal with adult-onset heredodegeneration. Donor Purkinje cells from extraparenchymal transplant sites migrated radially into the host molecular layer and differentiated. Donor Purkinje cell dendrites expanded to fill the host molecular layer, spinous processes were apparent, and axonal projections into the host gray and white matter were observed. Donor Purkinje cells remaining in the extraparenchymal transplant sites differentiated if they were located relatively close to the host cerebellum. Donor Purkinje cells located intraparenchymally in the host white matter or granule cell layer survived, but were stunted in their development. The orthogonal movement of donor Purkinje cells away from transplant sites in the host cerebellum was spatially restricted. The findings from this study indicate that host cerebellar cortex with adult-onset heredodegeneration of Purkinje cells supports the survival and differentiation of transplanted normal embryonic Purkinje cells.