Introduction: Surgical site infection following total hip replacement results in poorer outcomes, longer hospital stays, and increased costs. The aim of this study was to describe infective complications in a large series of total hip arthroplasty. Methods: Between January 1998 and March 2005, consecutive total hip arthroplasties were prospectively. The presence of deep infection was confirmed by culture from joint aspiration or a secondary procedure such as joint washout or component removal and replacement. Risk factors for development of surgical site infective complications were analysed. Results: 2029 consecutive total hip arthroplasties was carried out in 1539 patients. There were 22 deep infections (1.1%) and 118 superficial infections (5.8%). Staphylococcus aureus (MSSA) was isolated in 10/22 (45%) of deep infections and MRSA in 4 (18%). In patients undergoing unilateral replacement there were 11/1539 deep infections (0.7%) compared 5/172 (2.9%) in the bilateral simultaneous group. In patients who were current or exsmokers the deep infection rate was 11/880 (1.3%) compared to 7/864 (0.8%) in non-smokers. 3/120 (2.5%) diabetic patients developed deep infection. In patients who received a blood transfusion 9/502 (1.7%) developed deep infection compared to 13/1527 (1%) who did not. In patients with a BMI>35kgm −2 the overall rate of infective complications (superficial and deep) was 18.8%. In patients with a report of a perioperative complication the deep infection rate was 6/169 (3.6%) compared to 16/1860 (0.9%) without complication. Discussion: This study has the advantage of investigating infective complications in a typical case series of patient presenting for total hip replacement. The rate of deep infection was consistent with previous reports. Deep infection is associated with bilateral simultaneous replacement, smoking, diabetes, blood transfusion and perioperative complications. Obese patients are at higher risk of all surgical site infective complications.
Background: Median neuropathy is commonly associated with acromegaly, although its pathology is uncertain. Objective: To study the pathology of median neuropathy in acromegaly by using magnetic resonance imaging (MRI). Design: Case series. Setting: Outpatient clinic and MRI unit. Patients: Nine patients with acromegaly, four of whom had clinical symptoms of neuropathy. Measurements: At presentation and 6 months after treatment, median nerve size, its signal intensity, and the volume of the carpal tunnel contents were measured. Results: At presentation, patients with symptoms of neuropathy had increased nerve size and signal intensity compared with asymptomatic patients, but the two groups did not differ in volume of carpal tunnel contents. These measures improved with treatment of acromegaly in symptomatic patients; asymptomatic patients experienced no change or worsening. Conclusion: The predominant pathology of median neuropathy in acromegaly seems to be increased edema of the median nerve within the carpal tunnel rather than extrinsic compression from increased volume of the carpal tunnel contents.
Background : Early identification of atherosclerosis in older adults is paramount due to high cardiovascular morbidity and mortality. Our aim was to investigate CAC in a population of adults ≥55 years without previous history of cardiovascular heart disease (CHD) and its association with cardiovascular risk factors. Methods : This was a retrospective analysis of 6,573 individuals with a mean age of 61.8 years (range 55-85; 68.2% males) who underwent Electron Beam Computed Tomography for CAC score (CACS) assessment. Results : CAC was present in 70.5% of the overall cohort (78.8% of males and 52.7% of females). Twenty six per cent (26%) of those with CAC did not have any CHD risk factors. CACS ranged from 0 to 7,908 (mean 223.3±512.9); males presented a higher mean CACS (284.57 ± 571.1), compared to females (mean CACS 92.2 ± 324.8), p <0.0001. The mean CACS in males increased from 154.2 for ages 55-59 years to 760.2 in those aged 80 to 84 whilst in females mean CACS increased from 39.5 to 224.4, for corresponding age groups. The mean CACS appears to increase with age irrespective of gender. In each gender, age and hypercholesterolemia were associated with higher CACS. Furthermore, in males family history and DM were positively associated with CACS while in females, smoking status and hypertension were positively associated with CACS. Conclusion : A broad distribution of CACS was seen in older subjects. Assessment of CACS may place patients into a higher risk group for future events, and lead to more aggressive treatment with preventative therapies.
Although several studies have demonstrated the association between coronary artery calcification (CAC) and coronary artery disease events, the underlying mechanism has not been fully elucidated. Furthermore, extensive CAC still remains a poorly understood phenomenon. The objective of this study is to determine the clinical characteristics and differences between 831 asymptomatic individuals with very high CAC scores (CACS ≥1000) and 497 asymptomatic individuals with CAC scores of 400 to 999. Individuals with CACS ≥1000 were more likely to have hypertension ([HTN]; P = .0004), hypercholesterolemia ( P = .0001), diabetes mellitus ([DM] P = .005), and high body mass index ([BMI]; P = .03) compared with individuals with CACS = 400-999. On multivariable analysis, age ( P < .0001) and BMI ( P = .01) were found to be significant risk factors for the presence of very high CAC. While for males, age ( P < .0001), hypercholesterolemia ( P = .001), DM ( P = .002), and obesity ( P = .003) were independent risk factors; in females only HTN ( P = .04) was independent risk factor.
Background Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA. Methods A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion. Results Forty-nine eligible studies were identified ( n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2–30.9% and 11–13%, acute fracture 0–50% and 10–11%, trauma sequelae 14.2–50% and 0–30%, osteoarthritis 50% and 11%, respectively. Discussion TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.
Periprosthetic fracture is an uncommon but typically complex complication of cemented THA usually treated operatively. It is a source of reduced function, subsequent morbidity, and increased mortality. Previous studies may have underestimated the incidence of fracture through loss to followup or failure to use survivorship methodologies. The primary aim of this study was to use survivorship methodology to investigate the incidence of, and risk factors for fracture following primary arthroplasty. We examined a cohort of 6458 primary cemented femoral prostheses implanted during a 17-year period. One hundred twenty-four patients sustained fractures at the tip or below the femoral prosthesis. The incidence of fracture was 0.8% at 5 years and 3.5% at 10 years after primary implant. Patients older than 70 years had a 2.9 times greater risk of sustaining a subsequent fracture. There was no association between fracture and gender or implant type. These rates are higher than those reported for cemented arthroplasties. Older patients should be counseled regarding their higher risk of periprosthetic fracture, and additional research is required to elucidate the biologic mechanisms involved. Level of Evidence: Level II, retrospective prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Postoperative nausea and vomiting (PONV) are common side effects after surgery and have numerous patient factors and etiologies. Although self-limiting, PONV is not without risks and complications. In the past numerous antiemetics have been used successfully in the management of PONV; however, these drugs are associated with adverse effects. Ondansetron is a serotonin receptor antagonist that is effective in preventing and treating PONV. It is believed that ondansetron binds at the serotonin receptor both in the vagal afferents of the gastrointestinal tract and in the chemoreceptor trigger zone. The reported side effects from ondansetron are minor compared with those of the more commonly used antiemetics such as droperidol and metoclopramide and include headache, dizziness, musculoskeletal pain, drowsiness and sedation, and shivers.
The primary aim of this study was to identify factors associated with nonresponse to routinely collected patient-reported outcome measures (PROMs) after hand surgery. The secondary aim was to investigate the impact of nonresponder bias on postoperative PROMs. We identified 4357 patient episodes for which the patients received pre- and 1-year postoperative questionnaires. The response rate was 55%. Univariate and regression analyses were undertaken to determine factors predicting nonresponse. We developed a predictive model for the postoperative Quick version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores for nonresponders using imputation. Younger age, increasing deprivation, higher comorbidity, worse preoperative QuickDASH scores and unemployment predicted nonresponse. No significant difference in mean postoperative QuickDASH score was observed between the responders, and the scores for the responders combined with the predicted scores for the nonresponders. Preoperative function was the primary predictor of postoperative outcome. These results challenge the dogma that 'loss to follow-up' automatically invalidates the results of a study.Level of evidence: III.
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