Faculty Bibliography

The role of medical, social, and functional covariates on mortality after hip fracture was examined over a 16-year period. A total of 1109 patients with hip fractures were included in a prospective database. The inclusion criteria were patients who were age 65 years or older, ambulatory prior to fracture, cognitively intact, living in their own home at the time of the fracture, and had sustained a nonpathological femoral neck or intertrochanteric chip fracture. Data were analyzed using a Cox proportional hazards model. Mortality was compared with a standardized population, and standardized mortality ratios were calculated for 1, 2, 3, 5, and 10 years,respectively. The 1-, 2-, 5- and 10-year mortality rates were 11.9%, 18.5%, 41.2%, and 75.3%, respectively.The predictors of mortality were advanced age, male gender, high American Society of Anesthesiologists (ASA)classification, the presence of a major postoperative complication, a history of cancer, chronic obstructive pulmonary disorder, a history of congestive heart failure,ambulating with an assistive device, or being a household ambulator prior to hip fracture. The increased mortality risk was highest during the first year after hip fracture and returned to the risk of the standard population 3 years postoperatively. Males who are 65 to 84 years had the highest mortality risk

Core decompression may used in the management of early stage, precollapse nontraumatic osteonecrosis of the humeral head. We propose a technique without risk of complications associated with injury to the biceps tendon or the blood supply to the humeral head

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established nationwide guidelines for resident working environments and duty hours. Following these guidelines became a requirement for all accredited residency programs. Two years after implementation, we conducted a national survey to assess the opinions and attitudes of orthopedic residents and program directors toward the ACGME work-hour regulations and the effects of these regulations on resident education, resident quality of life, and patient care. Nine hundred seventy-six residents (30% response rate) and 85 program directors (56% response rate) completed the questionnaire. For resident education, junior residents were more likely than senior residents and program directors to perceive the work-hour regulations as having a positive effect on education. There was overall agreement among the 3 groups that resident quality of life had improved as a result of work-hour regulations. For patient care, junior residents viewed the new regulations positively for surgical training and patient care, whereas senior residents and program directors disagreed. This survey showed meaningful differences in the attitudes and opinions of junior residents, senior residents, and program directors toward the new ACGME work-hour regulations

The Orthopaedic In-Training Examination (OITE) is a tool used by residency directors to evaluate a resident's fund of orthopedic knowledge. In this study, we correlated resident study habits and preparation tools with performance on the OITE. Data analysis indicated statistically significant correlations between successful OITE performance and frequent review of current orthopedic journals (Journal of Bone and Joint Surgery-American Edition, r = .6, P < .001; Journal of the American Academy of Orthopaedic Surgeons, r = .36, P = .02), daily orthopedic reading (r = .34, P = .03), increased preparation time for OITE (r = .31, P = .04), and more hours committed to studying (r = .37, P = .01). In addition, residents who emphasized prior OITEs and self-assessment examinations when preparing had higher scores (r = .53, P < .001, and r = .64, P < .001, respectively). Our study results show that several factors, including structured study habits and use of specific study materials, contribute to residents' successful OITE performance. Adaptation of these findings by current orthopedic residents may have a positive impact on OITE performance

Controversy persists in the literature regarding the use of the bicipital groove as an anatomic landmark to restore humeral head retroversion when treating complex proximal humeral fractures with arthroplasty. We quantified the three-dimensional geometry of the bicipital groove in 49 dried humeri relative to the intramedullary axis, quantified the reliability of using the bicipital groove as an anatomic landmark, and compared this reliability with that of the conventional technique that uses a fixed, average angle relative to the epicondylar axis to establish humeral head retroversion. The data show the anterior offset of the bicipital groove is nearly constant from proximal (7.3 mm +/- 2.8 mm) to distal (7.2 mm +/- 1.5 mm) relative to the intramedullary axis. Given the consistency, the distal bicipital groove (at the level of the surgical neck) is a reasonable landmark to establish humeral head retroversion after complex proximal humeral fractures having reliability (angular error of 7.9 degrees +/- 5.8 degrees ) as good as or better than the conventional fixed-angle technique

The purpose of this report was to evaluate patient outcomes after treatment of acute midshaft clavicle fractures with an intramedullary Hagie pin, including clinical results and the incidence of postoperative complications. Between 1993 and 2003, 16 patients who underwent intramedullary Hagie pin fixation of a midshaft clavicle fracture were identified. The medical records of each patient were reviewed to ascertain the mechanism of injury, indication for surgical intervention, and treatment course. Clinical outcomes were evaluated with respect to time to fracture union, postoperative shoulder range of motion, and symptoms related to the fracture site and ipsilateral shoulder. The inpatient postoperative course and outpatient follow-up visits were assessed in an effort to document the incidence of postoperative complications. The most common mechanism of injury was participation in athletic activity. Operative indications included significant deformity, polytrauma, and neurovascular compromise. The mean time from injury to operative fracture stabilization was 15.8 days. No intraoperative complications occurred. All 16 patients (100%) were available for follow-up to fracture union, which occurred in all cases at a mean of 12.4 weeks. Of the 16 patients, 14 were available for further follow-up, and at a mean follow-up of 9 months, 85.7% had regained near-full to full range of shoulder motion and 93% had no symptoms related to the fracture site or ipsilateral shoulder. Postoperative complications occurred in 8 patients (50%), including 3 cases of skin breakdown related to hardware prominence, 2 cases of hardware breakage, 2 cases of decreased sensation in the region of the surgical incision, and 1 case of persistent pain over the operative site. When indicated, the use of intramedullary devices for the stabilization of clavicle fractures offers theoretic advantages over traditional plate and screw fixation. In this case series, intramedullary Hagie pin fixation resulted in fracture union in 100% of cases, with a high percentage of patients regaining full range of shoulder motion and resolution of symptoms. However, there was a 50% incidence of postoperative complications associated with this treatment method. We believe that the complication rate associated with the use of the Hagie pin should preclude the use of this particular implant.

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint that represents a complex interaction of the fibers of the coracohumeral ligament, the superior glenohumeral ligament, the glenohumeral joint capsule, and the supraspinatus and subscapularis tendons. As basic science and clinical studies continue to elucidate the precise role of the rotator interval, understanding of and therapeutic interventions for rotator interval pathology also continue to evolve. Lesions of the rotator interval may result in glenohumeral joint contractures, shoulder instability, or in lesions to the long head of the biceps tendon. Long-term clinical trials may clarify the results of current surgical interventions and further enhance understanding of the rotator interval.

This animal study evaluated the healing of supraspinatus tendon tears by use of a cartilage-derived morphogenetic protein 2 growth factor (CDMP-2) delivered to the repair. Forty-eight rats had bilateral, surgically created complete tears repaired by sutures with the growth factor introduced on one side. They were killed at 2, 3, 4, and 6 weeks, and the strength of the repairs was determined and histologic analysis performed. At 4 and 6 weeks, the CDMP-2-treated repairs were significantly stronger than the untreated repairs and histologic analysis showed more organized healing. The use of growth factors introduced at the time of rotator cuff repair might promote more rapid healing and subsequent, rapid patient rehabilitation

We compared the clinical efficacy and side-effect profiles of aspirin, dextran 40, and low-molecular-weight heparin (enoxaparin) in preventing thromboembolic phenomena after hip fracture surgery. All patients admitted with a diagnosis of hip fracture to our institution between July 1, 1987, and December 31, 1999, were evaluated. Study inclusion criteria were age 65 years or older, previously ambulatory, cognitively intact, home-dwelling, and having a nonpathologic intertrochanteric or femoral neck fracture. Each patient received mechanical thromboprophylaxis (above-knee elastic stockings) and 1 pharmacologic agent (aspirin, dextran 40, or enoxaparin); patients who received aspirin were also given a calf sequential compression device. Meeting the selection criteria and included in the study were 917 patients. Findings included low incidence of thromboembolic phenomena (deep vein thrombosis, 0.5%-1.7%; pulmonary embolism, 0%-2.0%; fatal pulmonary embolism, 0%-0.5%) and no difference among the 3 pharmacologic agents in thromboembolic prophylaxis efficacy. Use of enoxaparin was associated with a significant increase (3.8%) in wound hematoma compared with dextran 40 (1.6%) and aspirin (2.4%) (P<.01). The 3 agents were found not to differ with respect to mortality, thromboembolic phenomena, hemorrhagic complications, or wound complications.