Complications following 250 cemented modular hip hemiarthroplasties

Background and Aims:

Hemiarthroplasty is a common method of treating displaced femoral neck fractures, especially among elderly non-active patients with frailty syndrome. Complications arising from the use of a modern, modular hemiendoprosthesis via a posterior approach have been poorly reported in this population. The aim of this study was to evaluate complications and mortality associated with the use of Lubinus sp II cemented, unipolar hemiarthroplasty prosthesis and posterior approach during a 9-year follow-up.

Material and Methods:

All patients (244) who received hemiarthroplasty due to an acute fracture of the femoral neck in Central Finland Hospital, Jyvaskyla, Finland, during 2007 and 2008 were included. Patient records were retrospectively reviewed for intraoperative and postoperative complications.

Results and Conclusion:

Women composed 70% (n = 171) of the study population. Mean age was 83 years for women and 80 years for men. A total of 31 (12%) complications were found in 30 patients. These were 12 dislocations (5% of all patients), 5 (2%) periprosthetic fractures, 2 (0.8%) superficial and 5 (2%) deep infections, 1 (0.4%) protrusion of the prosthesis, 2 (0.8%) intraoperative fractures, and 2 (0.8%) partial sciatic nerve palsies. Conversion to total hip replacement was performed in 9 cases (4%) and a reoperation was required in 15 (6%) cases. Mortality rate at 9 years was 78% (95% confidence interval = 72%–83%). The overall rate of complications was acceptable although mortality was high in this comorbid patient population. The need for conversion to total hip arthroplasty and reoperation is low.

Scheduled Emergency Trauma Operation: The Green Line Orthopedic Trauma Surgery Process Of Care

BACKGROUND AND AIMS

Traditionally, patients requiring an orthopedic emergency operation were admitted to an inpatient ward to await surgery. This often led to congestion of wards and operation rooms while, for less urgent traumas, the time spent waiting for the operation often became unacceptably long. The purpose of this study was to evaluate the flow of patients coded green in a traffic light-based coding process aimed at decreasing the burden on wards and enabling a scheduled emergency operation in Central Finland Hospital.

MATERIALS AND METHODS

Operation urgency was divided into three categories: green (>48 h), yellow (8-48 h), and red (<8 h). Patients, who had sustained an orthopedic trauma requiring surgery, but not inpatient care (green), were assigned an operation via green line process. They were discharged until the operation, which was scheduled to take place during office hours.

RESULTS

Between January 2010 and April 2015, 1830 green line process operations and 5838 inpatient emergency operations were performed. The most common green line process diagnoses were distal radial fracture (15.4% of green line process), (postoperative) complications (7.7%), and finger fractures (4.9%). The most common inpatient emergency operation diagnosis was hip fracture (24.3%). Green line process and inpatient emergency operation patients differed in age, physical status, diagnoses, and surgical procedures.

CONCLUSION

The system was found to be a safe and effective method of implementing orthopedic trauma care. It has the potential to release operation room time for more urgent surgery, shorten the time spent in hospital, and reduce the need to operate outside normal office hours.

Short 2-H in Situ Trauma Team Simulation Training Effectively Improves Non-Technical Skills of Hospital Trauma Teams

BACKGROUND AND AIMS

As conducting the regular trauma team simulation training is expensive and time-consuming, its effects must be explored. The objective was to evaluate the efficacy of a structured 2-h in situ multiprofessional trauma team simulation training course on non-technical skills.

MATERIALS AND METHODS

This prospective study comprised 90 trauma teams with 430 participants. The structured, 2-h course consisted of an introductory lecture and two different simulations with debriefings. Data were collected using a pre-post self-assessment questionnaire. In addition, the expert raters used the T-NOTECHS scale.

RESULTS

The following non-technical skills improved significantly among both medical doctors and nurses: knowledge of the trauma resuscitation guidelines, problem identification, decision making, situation awareness/coping with stress, communication and interaction, time management, being under authority, and confidence in one's role in a team. The teams improved significantly in leadership, cooperation and resource management, communication and interaction, assessment and decision making, and situation awareness/coping with stress.

CONCLUSION

A short, structured 2-h in situ trauma team simulation training course is effective in improving non-technical skills.

Sixfold Post-Fracture Mortality in 16- To 30-Year-Old Patients-Suicides, Homicides, and Intoxications Among Leading Causes of Death

BACKGROUND AND AIMS:

The death of any young individual is associated with the loss of many potentially fulfilling years of life. It has been suggested that the relative mortality of fracture patients may be higher in younger age groups than in older cohorts. We determined the mortality and causes of death in a cohort of 16- to 30-year-old patients that had been hospitalized for fractures.

MATERIAL AND METHODS:

We collected data using criteria based on the diagnosis code (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), surgical procedure code (Nordic Medico-Statistical Committee), and seven additional characteristics of patients admitted to the trauma ward at the Central Finland Hospital between 2002 and 2008. Patients were then followed to ascertain their mortality status until the end of 2012. Standardized mortality ratios were calculated and causes of death were determined by combining our registry data with data provided by Statistics Finland.

RESULTS:

During the study, 199 women and 525 men aged 16-30 years had sustained fractures. None of these patients died during the primary hospital stay. At the end of follow-up (mean duration 7.4 years), 6 women and 23 men had died. The standardized mortality ratio for all patients was 6.2 (95% Confidence Interval: 4.3-8.9). Suicides and intoxications comprised over half, and motor vehicle accidents and homicides comprised nearly a third of the post-fracture deaths.

CONCLUSION:

We found a concerning increase in mortality among young adults that had been hospitalized due to a fracture compared to the general population that had been standardized by age, sex, and calendar-period. Leading causes of death were suicides and intoxications or motor vehicle accidents and homicides, which may be indicative of depressive disorders or impulse control disorders, respectively. Identification of the underlying psychosocial problems may provide an opportunity for preventive interventions.

Efficacy of progressive aquatic resistance training for tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis: a randomised controlled trial

OBJECTIVE

To study the efficacy of aquatic resistance training on biochemical composition of tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis (OA).

DESIGN

Eighty seven volunteer postmenopausal women, aged 60-68 years, with mild knee OA (Kellgren-Lawrence grades I/II and knee pain) were recruited and randomly assigned to an intervention (n = 43) and control (n = 44) group. The intervention group participated in 48 supervised aquatic resistance training sessions over 16 weeks while the control group maintained usual level of physical activity. The biochemical composition of the medial and lateral tibiofemoral cartilage was estimated using single-slice transverse relaxation time (T2) mapping and delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC index). Secondary outcomes were cardiorespiratory fitness, isometric knee extension and flexion force and knee injury and OA outcome (KOOS) questionnaire.

RESULTS

After 4-months aquatic training, there was a significant decrease in both T2 -1.2 ms (95% confidence interval (CI): -2.3 to -0.1, P = 0.021) and dGEMRIC index -23 ms (-43 to -3, P = 0.016) in the training group compared to controls in the full thickness posterior region of interest (ROI) of the medial femoral cartilage. Cardiorespiratory fitness significantly improved in the intervention group by 9.8% (P = 0.010).

CONCLUSIONS

Our results suggest that, in postmenopausal women with mild knee OA, the integrity of the collagen-interstitial water environment (T2) of the tibiofemoral cartilage may be responsive to low shear and compressive forces during aquatic resistance training. More research is required to understand the exact nature of acute responses in dGEMRIC index to this type of loading. Further, aquatic resistance training improves cardiorespiratory fitness.

TRIAL REGISTRATION NUMBER

ISRCTN65346593.

Relationship between lower limb neuromuscular performance and bone strength in postmenopausal women with mild knee osteoarthritis

OBJECTIVES

To investigate whether neuromuscular performance predicts lower limb bone strength in different lower limb sites in postmenopausal women with mild knee osteoarthritis (OA).

METHODS

Neuromuscular performance of 139 volunteer women aged 50-68 with mild knee OA was measured using maximal counter movement jump test, isometric knee flexion and extension force and figure-of-eight-running test. Femoral neck section modulus (Z, mm(3)) was determined by data obtained from dual-energy X-ray absorptiometry. Data obtained using peripheral quantitative computed tomography was used to asses distal tibia compressive (BSId, g(2)/cm(4)) and tibial mid-shaft bending (SSImax(mid), mm(3)) strength indices.

RESULTS

After adjustment for height, weight and age, counter movement jump peak power production was the strongest independent predictor for Z (β=0.44; p<0.001) and for BSId (β=0.32; p=0.003). This was also true in concentric net impulse for Z (β=0.37; p=0.001) and for BSId (β=0.40; p<0.001). Additionally, knee extension force (β=0.30; p<0.001) and figure-of-eight-running test (β= -0.32; p<0.001) were among strongest independent predictors for BSId after adjustments. For SSImax(mid), concentric net impulse (β=0.33; p=0.002) remained as the strongest independent predictor after adjustments.

CONCLUSIONS

Neuromuscular performance in postmenopausal women with mild knee OA predicted lower limb bone strength in every measured skeletal site.

Exercise therapy is evidence-based treatment of shoulder impingement syndrome. Current practice or recommendation only

BACKGROUND

Subacromial impingement syndrome is the most common indication for shoulder operation. However, exercise therapy for the conservative treatment is recommended in the first instance.

AIM

To evaluate the implementation of exercise therapy in impingement syndrome.

DESIGN

Retrospective study using structured postal questionnaire and data collected from hospital archive.

METHODS

A total of 104 consecutive patients who had undergone shoulder surgery due to impingement syndrome. Patients were asked about therapy modalities that they had received before and after the operation as well as pain (VAS) and functional impairment (ASES) at one-year follow-up.

RESULTS

Before surgery 49% of patients had not received advice for shoulder muscle exercises. After operation all patients had received mobility exercises, but one quarter of patients still reported that they had not received instructions about shoulder strength exercises. At the follow-up the means of the ASES index was 85 and use of NSAID had decreased by 75%. However, 15% of patients had moderate functional impairment (ASES under 60).

CONCLUSION

About half of patients reported that they had not received advice for rotator cuff exercise therapy before surgery even though with it surgery would probably have been avoided in many cases. Although symptoms in most patients had decreased after operation, several patients still suffered from pain and decreased function. Still several patients had not received advice for shoulder strengthening exercises that are important to recovery.

CLINICAL REHABILITATION IMPACT

The adherence to the current recommendations about exercise therapy is insufficient in clinical practice. Thus we recommend that it should be monitored in all institutions in which shoulder pain is treated.

The genetic causes of basal ganglia calcification, dementia, and bone cysts: DAP12 and TREM2

BACKGROUND

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy (PLOSL), or Nasu-Hakola disease, is a presenile dementia associated with loss of myelin, basal ganglia calcification, and bone cysts. It is caused by recessively inherited mutations in two genes encoding subunits of a cell membrane-associated receptor complex: TREM2 and DAP12. The clinical course of PLOSL has not been characterized in a series of patients with TREM2 mutations.

METHODS

The authors compare neurologic and neuroradiologic follow-up data of six patients carrying TREM2 mutations with PLOSL due to defective DAP12 genes. The authors review the known mutations in these two genes.

RESULTS

Mutations in DAP12 and TREM2 result in a uniform disease phenotype. In Finnish and Japanese patients with PLOSL, DAP12 mutations predominate, whereas TREM2 is mutated more frequently elsewhere.

CONCLUSIONS

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy should be considered in adult patients under age 50 years with dementia and basal ganglia calcification. Radiographs of ankles and wrists, and DNA test in uncertain cases, confirm the diagnosis.

Loss-of-function mutations in TYROBP (DAP12) result in a presenile dementia with bone cysts

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy (PLOSL; MIM 221770), also known as Nasu-Hakola disease, is a recessively inherited disease characterized by a combination of psychotic symptoms rapidly progressing to presenile dementia and bone cysts restricted to wrists and ankles. PLOSL has a global distribution, although most of the patients have been diagnosed in Finland and Japan, with an estimated population prevalence of 2x10-6 (ref. 2) in the Finns. We have previously identified a shared 153-kb ancestor haplotype in all Finnish disease alleles between markers D19S1175 and D19S608 on chromosome 19q13.1 (refs 5,6). Here we characterize the molecular defect in PLOSL by identifying one large deletion in all Finnish PLOSL alleles and another mutation in a Japanese patient, both representing loss-of-function mutations, in the gene encoding TYRO protein tyrosine kinase binding protein (TYROBP; formerly DAP12). TYROBP is a transmembrane protein that has been recognized as a key activating signal transduction element in natural killer (NK) cells. On the plasma membrane of NK cells, TYROBP associates with activating receptors recognizing major histocompatibility complex (MHC) class I molecules. No abnormalities in NK cell function were detected in PLOSL patients homozygous for a null allele of TYROBP.

Fine-scale mapping of a novel dementia gene, PLOSL, by linkage disequilibrium

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy (PLOSL; MIM 221770) is a rare hereditary cause of presenile dementia with autosomal recessive inheritance. Its unique feature is the cystic bone lesions that accompany the dementia. About 160 cases have been reported to date, mostly in Finland and Japan. The etiology and pathogenesis of PLOSL are unknown. We recently assigned the locus for PLOSL in the Finnish population to chromosome 19q13.1 (P. Pekkarinen et al., 1998, Am. J. Hum. Genet. 62, 362-272). In the present study, we restrict the critical region for PLOSL to 153 kb by linkage-disequilibrium mapping. First, three new microsatellite markers were revealed in the PLOSL critical region. These and three other markers spanning the critical region were analyzed in Finnish PLOSL families. Strong linkage disequilibrium (multipoint P value < 10(-47)) was detected between the markers and PLOSL, and for two markers, D19S1176 and D19S610, all the PLOSL chromosomes shared identical 171- and 218-bp alleles, respectively. Haplotype analysis revealed five different haplotypes in the Finnish PLOSL chromosomes. But all of them shared the region between markers D19S1175 and D19S608 that could be traced to one ancestor haplotype by single recombination events, thus defining the critical region as 153 kb. Multipoint association analysis also assigned the most likely location of the PLOSL locus within this interval to the immediate vicinity of marker D19S610. A promising positional candidate for PLOSL, an amyloid precursor-like protein, was studied by sequencing, but no mutations were detected. These results lay the basis for the cloning of this novel dementia gene and for diagnostics in the Finnish population using haplotype analysis.