Cardiac overscreening hip fracture patients

BACKGROUND

The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome.

METHODS

This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality.

RESULTS

According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality.

CONCLUSION

Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality.

LEVEL OF EVIDENCE

II.

Preoperative cardiac evaluation of geriatric patients with hip fracture

BACKGROUND

The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed guidelines for perioperative assessment of patients in case of non-cardiac surgery. The aim of this study was to investigate if the preoperative cardiac evaluation of geriatric patients with hip fracture was in accordance with these guidelines and what the effects were on outcome.

METHODS

In a retrospective study 388 patients with hip fracture treated in the department of Trauma surgery of the Maastricht University Medical Centre in the Netherlands were included. All patients were treated between 2003 and 2006 and had at least two year follow-up. The preoperative cardiac screening was analysed with respect to content and to which level this followed the ACC/AHA guidelines. These guidelines were used to classify cardiac risk into low, intermediate and high risk. This was related to the outcome measurements delay to surgery, perioperative complications and mortality.

RESULTS

According to the ACC/AHA guidelines 82% of patients received correct preoperative cardiac screening in the low vs. 46% in the intermediate and 86% in the high risk group. The most frequent reason for incorrect preoperative cardiac screening was overscreening (>95%). The delay to surgery increased by 9.9h in the case of overscreening (p=0.03). A previous cardiac history was a significant risk factor for early mortality. Delay of >48 h was associated with more cardiovascular complications and mortality both on univariate and multivariate analysis.

CONCLUSION

Preoperative cardiac screening is frequently unnecessary after hip fracture, especially in patients with intermediate risk predictors and increases the delay to surgery. Delay of >48 h was associated with more cardiovascular complications and mortality postoperatively. The implementation of the ACC/AHA guidelines may prevent unnecessary cardiac consultations which reduces preoperative resources, delay to surgery and possibly decreases postoperative complications.

Ten-year mortality among hospitalised patients with fractures of the pubic rami

In a case-control study, 99 patients aged over 60 years and admitted to hospital with an isolated single fracture of the pubic ramus were compared with age- and gender-matched patients without fractures, in terms of morbidity and mortality. Ten years of follow-up showed that the survival of patients with an isolated pubic ramus fracture was significantly lower than that of controls. The mortality rates of patients with isolated pubic ramus fractures at 1, 5 and 10 years were 24.7%, 64.4% and 93.8%, respectively. One-third of the mortality was due to cardiovascular events. A 20.2% complication rate was found during hospital admission, mainly caused by infectious diseases, including urinary tract infection and pneumonia. Thirty-three percent of the patients were temporarily or permanently admitted to a nursing home, because they were unable to mobilise independently. In conclusion, our study found significant morbidity and mortality among patients admitted to hospital for an isolated pubic ramus fracture, both during hospital admission and during 10 years of follow-up.

Humeral fractures in the elderly: treatment with a reamed intramedullary locking nail

In the elderly person, comorbidities combined with lower functional demands tend to indicate non-operative treatment; however, fast functional recovery is mandatory to prevent loss of independency and social ability. This retrospective follow-up study included 40 people with a mean age of 75 (range 60-87) years. They had all received treatment with a reamed intramedullary nail for humeral fracture; 21 were operated after a mean of 6 (range 0-16) days, and 19 after a mean of 28 (range 9-63) days after a primary decision for non-operative treatment. In all, 5 cases (12.5%) were lost to follow-up. The primary healing rate was 94% (33/35) after a mean of 17 (range 6-61) weeks; 14% (5/35) needed re-operation, in 2 cases because of healing problems. Functional results could be assessed in 18 cases: the median Neer score was 90 (range 45-97) points and the median Morrey score 98 (range 74-100) points. The relative functional scores were 94 (range 89-101) and 100 (range 97-100) points, respectively. All functional scores were independent of introduction site and time to treatment. On the basis of these results we conclude that treatment of humeral fractures in the elderly with an intramedullary nail leads to good healing and functional results, and an acceptable re-operation rate.

Endovascular treatment of traumatic rupture of the thoracic aorta

Background

Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.

Methods

A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.

Results

A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.

Conclusion

Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.

Failure of reamed nailing in humeral non-union: an analysis of 26 patients

The use of an intramedullary nail in the treatment of humeral non-unions remains controversial. This study evaluated the treatment of humeral delayed and non-unions with reamed nailing and compression. In a retrospective analysis of prospectively gathered data from 26 cases all treated with the Telescopic Locking Nail (TLN), the healing rate after the first intervention for non-union was 58%. After one or more re-interventions combined with an external cancellous bone graft at some time during follow-up, 90% of the 21 patients with complete follow-up eventually healed after a mean of 22 months. A total of 49 procedures with a mean of 1.9 per patient were needed. After a mean follow-up of 65 (range 24-88) months, we conducted a study to assess the functional results in the shoulder and elbow. Twelve patients were suitable for inclusion. We used the Neer and Morrey score for shoulder and elbow function, respectively. For the Neer score the median was 91 points and for the Morrey score 94 points. The outcome suggests that simple reamed nailing of humeral non-union is insufficient. Reamed interlocked nailing is feasible, provided that the primary intervention for non-union is combined with an external cancellous bone graft.