sábado, 25 de marzo de 2017

Cirugía de ortopedia en el anciano / Orthopedic surgery in the elderly

Marzo 24, 2017. No. 2638

El aumento aislado de troponina cardiaca no modifica el pronóstico de pacientes geriátricos con fractura de cadera
Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture.
Medicine (Baltimore). 2017 Feb;96(7):e6169. doi: 10.1097/MD.0000000000006169.
Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.... ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

Artroplastía total de cadera. Seguimiento a 5 años de la evolución funcional pacientes independientes viejos y muy viejos
Total hip arthroplasty for hip fractures: 5-year follow-up of functional outcomes in the oldest independent old and very old patients.
Geriatr Orthop Surg Rehabil. 2014 Mar;5(1):3-8. doi: 10.1177/2151458514520700.
INTRODUCTION: This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care. METHOD: Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery-geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury. RESULTS: Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged. CONCLUSION: This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury.
KEYWORDS: geriatrics; hip fractures; orthogeriatric team; perioperative care; total hip arthroplasty

Mortalidad postoperatoria después de cirugía para fractura de cadera. Seguimiento a tres años
Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up.
PLoS One. 2016 Oct 27;11(10):e0162097. doi: 10.1371/journal.pone.0162097. eCollection 2016.
BACKGROUND AND AIMS: To determine mortality rates and predisposing factors in patients operated for a hip fracture in a 3-year follow-up period. METHODS: The study included patients who underwent primary surgery for a hip fracture.The inclusion criteria were traumatic, non-traumatic, osteoporotic and pathological hip fractures requiring surgery in all age groups and both genders. Patients with periprosthetic fractures or previous contralateral hip fracture surgery and patients who could not be contacted by telephone were excluded. At 36 months after surgery, evaluation was made using a structured telephone interview and a detailed examination of the hospital medical records, especially the documents written during anesthesia by the anesthesiologists and the documents written at the time of follow-up visits by the orthopaedic surgeons. A total of 124 cases were analyzed and 4 patients were excluded due to exclusion criteria. The collected data included demographics, type of fracture, co-morbidities, American Society of Anesthesiologists (ASA) scores, anesthesia techniques, operation type (intramedullary nailing or arthroplasty; cemented-noncemented), peroperative complications, refracture during the follow-up period, survival period and mortality causes. RESULTS: The total 120 patients evaluated comprised 74 females(61.7%) and 46 males(38.3%) with a mean age of 76.9±12.8 years (range 23-95 years). The ASA scores were ASA I (0.8%), ASA II (21.7%), ASA III (53.3%) and ASA IV (24.2%). Mortality was seen in 44 patients (36.7%) and 76 patients (63.3%) survived during the 36-month follow-up period. Of the surviving patients, 59.1% were female and 40.9% were male.The survival period ranged between 1-1190 days. The cumulative mortality rate in the first, second and third years were 29.17%, 33.33% and 36.67% respectively. The factors associated with mortality were determined as increasing age, high ASA score, coronary artery disease, congestive heart failure, Alzheimer's disease, Parkinson's disease, malignancycementation and peroperative complications such as hypotension (p<0.05). Mortality was highest in the first month after fracture. CONCLUSION: The results of this study showed higher mortality rates in patients with high ASA scores due to associated co-morbidities such as congestive heart failure, malignancy and Alzheimer's disease or Parkinson's disease. The use of cemented prosthesis was also seen to significantly increase mortality whereas no effect was seen from the anesthesia technique used. Treatment of these patients with a multidiciplinary approach in an orthogeriatric ward is essential. There is a need for further studies concerning cemented vs. uncemented implant use and identification of the best anesthesia technique to decrease mortality rates in these patients.

Curso sobre Anestesia en Trasplantes, Cirugía abdominal, Plástica, Oftalmología y Otorrinolaringología.
Committee for European Education in Anaesthesiology (CEEA) 
y el Colegio de Anestesiólogos de León A.C.
Abril 7-9, 2017, León Guanajuato, México

Informes  (477) 716 06 16, kikinhedz@gmail.com
Congreso Latinoamericano de Anestesia Regional
Asociación Latinoamericana de Anestesia Regional, Capítulo México
Ciudad de México, Mayo 24-27, 2017
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