Let’s look at a real live case. This was a 52 year old male who was vacationing with his wife when he fell down a flight of stairs. He was brought immediately to the hospital after the injury and arrived within 2 hours of the fall on a Sunday evening at about 8 p.m. He had just finished dinner at 5 p.m. and had fallen on the way back to his hotel. In his normal occupation he works at a desk, he does not smoke, does not drink, does not have diabetes but he is relatively sedentary and reports that his favorite activity is using his computer. His body mass index is 30. The astute emergency department physician noticed that he had an abnormally-widened mediastinum on his pre-operative chest x-ray and obtained a CT scan of his chest. This demonstrated a massive, enlarged esophagus with a significant amount of partially-digested foodstuffs. He related to the ER doctor that many of his family members suffered from the same complaints of gastric upset, belching, and they all needed to sit upright for long periods after eating a meal.
A secondary trauma survey also revealed that he had minimally displaced fractures of the left radial head (the same side as the femoral neck fracture), and a non-displaced fracture of the ipsilateral fibula. What a mess! This patient is, by today’s standards, pretty young. However, he is not terribly active. He has a belly full of food but he has a very unusual condition with dilation of the esophagus that puts him at high risk of an adverse event if he were to be put under anesthesia. Specifically, there is a very high likelihood that he may aspirate and develop a severe pulmonary complication if he is operated on immediately. In my discussions with the family, it became apparent that they were much less concerned about the possibility of AVN than the potential complications that could occur during surgery. However, they also wanted to avoid a “half of a hip replacement”. I explained to them that I had no idea how to quantify his risk of AVN, nor could I say with any certainty that 6 or 8 or 10 or 12 hours without eating would be sufficient to reduce his risk of aspiration. Ultimately we agreed that we would postpone surgery until the next day and I would get one of our experienced cardiac anesthesiologists to perform anesthesia.
The next day, nearly 20 hours after the fall, he was taken to the operating room. The anesthesiologist was observant enough to note that the patient’s mother had a pseudocholinesterase deficiency and had required a prolonged period on a ventilator after a routine operation, but there was no way to tell if this patient had the same deficiency since he had never had an operation prior to this one. In the end, the anesthesiologist chose to pre-medicate the patient with a non-particulate antacid that would reduce the threat to his lungs if the patient aspirated the contents of his esophagus, and he performed a rapid-sequence intubation with the head of the bed elevated to 45 degrees. The induction went as smooth as silk, and the orthopedic side of the procedure — closed reduction and percutaneous screw fixation without an open capsulotomy was the easiest part of the entire hospitalization.
In my mind, we attempted to balance several goals: I wanted to obtain an immediate anatomic reduction but I needed to be mindful of the patients multiple other medical problems. His relative sedentary lifestyle may mitigate the significance of AVN and the need to proceed with a hemiarthroplasty in the future, and in addition I had to deal with the uncertainty of getting a patient that none of us had ever met before with a number of extremely unusual variables — dilated esophagus, family history of pseudocholinesterase deficiency — through an anesthetic and an operation safely.