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M & M M & M Rounds for Rounds for UAHUAH

September 12, 2001Dr. Abdulaziz Al-Ahaideb

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M & M Rounds for UAHM & M Rounds for UAH

September 12, 2001

Dr. Abdulaziz Al-Ahaideb

University of Alberta

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MORTALITYMORTALITY

6 mortalities

Four “expected”

Two “unexpected”

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”

Mr. C. G. is a 69 y. o.PMHx: DM, CRF, HTNAdmitted July 11/03 for pain controlMVA Iliac wing # R, # ribs , C-spine ? Soft

tissue swelling

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”

In hospital: – Dec. LOC CT head X3 age-related

changes– C spine cleared C&R– Ileus– Arrhythemia cardiology involved– Dec. Hb urgent endoscopy N– Required dialysis

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”

Code status D/W family DNRPronounced deceased on Aug 3/03Autopsy: ischemic gut

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”

Mr. L .D is a 76 y. o.PMHx: L THA 1989July 4 uncomplicated revision of

acetabular cup and linerPOD 7 July 11 abdominal distention and

hematemesisHb 85 down from 106

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MORTALITY - MORTALITY - “Unexpected”“Unexpected”Central line inserted by the senior

residentUrgent GI consultWhile awaiting to reverse

anticoagulation pt codedResuscitated .. 20 min of down timeIntubated and transferred to CCU

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MORTALITY - MORTALITY - “Unexpected”“Unexpected” Blood products given , urgent CT

abdomen: no ruptured vesicus July 12 gastroscopy done, multiple

gastric ulcers,, no active bleeding No neurological response + hemodynamic

instability Family conference compassionate care Pronounced deceased July 12

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MORBIDITYMORBIDITY

Not necessarilyOurs !!

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CASE 1CASE 1

Mrs. A. N is a 67 y.oSustained L proximal tibial # Uneventful open reduction and

internal fixation was done

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CASE 1CASE 1

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CASE 1CASE 1

POD 7 fell and complained of pain at the thoracic spine

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CASE 1CASE 1

She sustained T10 compression fracture, treated conservatively

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CASE 2CASE 2

Mrs. S. P is a 75 y. o.PMHx: COPD, CAD, R THASustained L subcapital #Aug 11 L Modular Moore

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CASE 2CASE 2

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CASE 2CASE 2

Postop resp failure and NSTEMI ,, required ICU

Transferred to Fort McMurray in good Aug 25 started to drain from the wound,

then the wound dehisced Aug 27 back to UAH Aug 30 debridement and insertion of

gentamicin beads

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CASE 2CASE 2

Sep 1 culture grows enterococcus Sep 2 2nd debridement Sep 5 was supposed to go for 3rd

debridement and possible removal of prosthesis but developed new problems :– CHF– Dec urine output– Incr troponin

Hematology has seen here recently ? Lupus factor

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CASE 2CASE 2

Sep 8/03 Troponin 4.1 N ECGMedicine and hematology are

following

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CASE 3CASE 3

Mrs. M. C is a 60 y. o.Nov 02 elective lumbar discectomy

and instrumentationJan 03 deep infection

debridement and removal of hardware

Had been reasonably well till Aug 03, developed fever and malaise

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CASE 3CASE 3

Ultimately developed staph aureus septicemia and draining from the wound

Admitted to ICUUrgent MRI

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CASE 3CASE 3

•Aug 9 Urgent to ORDebridement and irrigation•Aug 11 repeat debridement and closure with retention sutures•Cardiology: MIBI and TEE•Sep 5 taken to the OR as the wound started to drain

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CASE 4CASE 4

Mr. C.L is a 40 y. o. PMHx: – R ACL reconstruction 20 yrs ago in

Ottawa– Taek-wan-do injury , found to have R

knee in varus– Feb 03 HTO (+? tubercle

osteotomy+allograft) was done by the same surgeon in Ottawa

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CASE 4CASE 4

Was able to walk without aidsR leg looked crooked Clinically R leg in varus and lack of

full extension

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CASE 4CASE 4

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CASE 4CASE 4

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CASE 4CASE 4

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CASE 4CASE 4

Sep 4/03 to the OR spinalRemoval of the hardwareNew fixation with 2 platesBone grafting from R iliac crest

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CASE 4CASE 4

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CASE 4CASE 4

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CASE 5CASE 5

Mrs. J. M is a 54 y. o.Involved in MVAGCS 5/15 on scene, intubated in

Prince George ERSent to Grande Prairie

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CASE 5CASE 5

Injuries:– Basal skull #– Small subarachnoid bleed– Bilat. Hemopneumothoraces– R sup/ inf pubic rami #– R midshaft tibia – ex fixed – L distal radius/ulna ORIF– L calcaneus #– R Lisfranc # dislocation

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CASE 5CASE 5

Injuries dealt with @ UAH on admission Aug 7– Ex-fix for R wrist – I & D L knee laceration

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CASE 5CASE 5

– Cannulated screws for L hip # (Aug 5)

– Satisfactory fixation

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CASE 5CASE 5

Repeat x-rays after discharge from ICU

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CASE 5CASE 5

Aug 29 to ORRemoval of the cannulated screws

and bipolar hemiarthroplasty

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CASE 5CASE 5

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CASE 6CASE 6

Mrs. S. F 44 y. o. chronic alcoholicJuly 4/03 seen @ Invuik hospital with

C/O neck , shoulder and arm pain bilaterally after falling 10 steps ( ? Abuse)

“C-spine x-rays were unchanged” , also CT spine done N

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CASE 6CASE 6

Admitted there for bowel obstructionGot worse neurologically: weakness

& numbness to the level of nipplesIntubated due to dec. O2 satTo Stanton QUADREPLEGIC

working Dx Gullian Barre synd.

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CASE 6CASE 6

July 19 transferred to UAH to R/O spinal injury

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CASE 6CASE 6

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CASE 6CASE 6

Diagnosed to have bilateral jump facet C7 on T1

What should be done ?

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CASE 6CASE 6

With 20 Ibs With 72 Ibs

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CASE 6CASE 6

Traction unsuccessful (even with 72 Ibs)

35 Ibs left on overnightCT C-spine done

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CASE 6CASE 6

CT shows partialreduction

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CASE 6CASE 6

July 11 to OR: posterior instrumentation and fusion C6 to T2

Was not stable enough

Halo vs ant. plating

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CASE 6CASE 6

July 15 C7-T1 anterior discectomy, partial corpectomy, tricortical bone grafting and anterior plating

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CASE 7CASE 7

Mr. W. H 48 y. o.PMHx:– Obesity– DM– Peripheral neuropathy– NSTEMI – Chronic renal impairment

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CASE 7CASE 7

Apr 03 sustained L ankle #Seen @ RAH – treated in a cast then a walking cast – # displaced pressure ulcer laterally

infected with soft tissue defect and exposed bone

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CASE 7CASE 7

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CASE 7CASE 7

Pt wants to keep his legAdmitted to UAH ICU with another

NSTEMIRequired hemodialysisNot a candidate for CABGStill wants to keep his leg

What should be done ?

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CASE 7CASE 7

Irrigation & debridementResection of articular surfacesEx-Fix with an attempt to fuseWound closed primarily

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CASE 8CASE 8

Mrs. N. J is a 69 yo PMHx: HTN L hip OA

June 19

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CASE 8CASE 8

June 23/03 uncomplicated L THA

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CASE 8CASE 8

Fell at homeCouldn’t wt bearNo hx of constitutional symptoms

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CASE 8CASE 8

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CASE 8CASE 8

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CASE 8CASE 8

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CASE 8CASE 8

Work up for infection – negativeOR July 31/03– Removal of the cup– ORIF posterior wall– Allograft– Recon ring & cemented liner

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CASE 8CASE 8

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CASE 9CASE 9

Mrs. M.K is a healthy 44 y.o. womanSustained L distal radius #Outside filmsAug 1/03 closed reduction and perc.

pinning

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CASE 9CASE 9

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CASE 9CASE 9

2 weeks post-op

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CASE 9CASE 9

Aug 25 Revised with a volar plate

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CASE 9CASE 9

At night , developed paresthesia and numbness ( carpal tunnel like )

Wound was opened in the ward partial relief

Aug 27 irrigation and debridement

Wound wasn’t closableAug 30 2nd debridement & closure..

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CASE 10CASE 10

Mr. L. N is an 83 yo malePMHx: CHF, A.fibPSHx:– 5 revisions L hip – 2 revisions R hip– L TKA

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CASE 10CASE 10

July 17 fell at home and C/O of L hip pain

No Hx of fever, chills or night sweats

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CASE 10CASE 10

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CASE 10CASE 10

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CASE 10CASE 10

Infection work up negativeJuly 29 to OR– Revision of the stem to a longer one– Strut allograft– Dall-Miles cables

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CASE 10CASE 10

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CASE 10CASE 10

2 weeks post-op: ill, fever, erythema, Left leg swelling

Aug 17 L hip irrigation & debridement + genta beads + removal of the cables

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CASE 10CASE 10

Aug 20 2nd debridement L hip and excision of necrotic skin L leg

Stable componentsSep 7 debridement + removal of

beads + closure of wound, good hemostasis + debridement of L leg by plastics

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CASE 10CASE 10

@ 2240 the resident called Re: low BP soaking dressing Hb 59

Medicine consulted to R/O DICLost > 10 units total but eventually

bleeding is less

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CASE 11CASE 11

Mr. L. B is a 23 y.o. male MVA 3 Aug 03 Multiple injuries, arrived intubated Ortho injuries:– L midshaft femur– L open midshaft tibia– L tibial plateau– L open humerus– L ulna

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CASE 11CASE 11

L humerus #

L ulna #

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CASE 11CASE 11

OR Aug 4 – I&D + plating L humerus– Plating L ulna– IM nail L femur

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CASE 11CASE 11

L femur L humerus

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CASE 11CASE 11

Aug 20 from ICU to the wardL wrist dropPain L kneeRepeat x-rays

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CASE 11CASE 11

L humerus

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CASE 11CASE 11

L ulna L knee

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CASE 11CASE 11

Aug 24 to OR– Exchange locking screw L distal femur– Revision ORIF L ulna– Revision ORIF L humerus and

exploration of radial nerve

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CASE 11CASE 11

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Interesting techniqueInteresting technique

Ms S.E is a 29 y.oHad internal tortion of the femur with

zero external rotationPLAN: derotational femoral

osteotomy

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Interesting techniqueInteresting technique

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Interesting techniqueInteresting technique

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Interesting techniqueInteresting technique

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Thank You