Faculty Bibliography

The surgical treatment of recurrent posterior shoulder instability via a posterior approach has had a variable degree of success reported in the literature with recurrence rates ranging between 8% and 45%. The purpose of this study was to review the results of posterior capsulorrhaphy in a consecutive series of patients with recurrent posterior instability. Seventeen consecutive patients underwent operative management for posterior glenohumeral instability. The dominant shoulder was involved in ten patients. All patients were male with an average age of 28.1 years (range: 16 to 54 years). Ten patients had sustained a specific injury which precipitated the instability. Six patients reported dislocations requiring formal closed reduction maneuvers; the remainder described episodes of recurrent subluxation with spontaneous reduction. All patients underwent a posterior capsulorrhaphy using an infraspinatus splitting approach. Eight shoulders required repair of a posterior capsulolabral detachment. In addition, one patient required augmentation with a posterior bone block for significant glenoid rim deficiency. Outcome was assessed by personal interview, clinical assessment, and standardized radiographs. At an average follow-up of 3.9 years (range: 1.8 to 10.8 years) patients estimated their overall shoulder function to be 81% of the contralateral unaffected shoulder. The subjective result was excellent for eight patients, good for five patients, fair in two patients, and poor in two patients. One of the poor outcomes was in a patient with glenohumeral degenerative changes at the index procedure which progressed and eventually required a total shoulder arthroplasty. The other poor result was in a patient found to have a full-thickness rotator cuff tear 10.6 years after the index procedure. Two patients (12%) had recurrence of their instability. Both of these patients sustained a significant re-injury which precipitated their symptoms. Five patients complained of occasional night pain at the time of their last follow-up examination. Only one patient (who was re-injured) had to change professions as a result of shoulder symptoms. Posterior capsulorrhaphy for treatment of isolated posterior glenohumeral instability yields satisfactory clinical results. Recurrent instability in this series was associated with a specific re-injury and did not appear to increase with longer follow-up

The purpose of this study was to determine the effect of the last hemoglobin level before patient discharge on outcome after hip fracture. We retrospectively reviewed data prospectively collected from July 1987 to December 1997 on 844 community-dwelling patients 65 or older who had sustained an operatively treated femoral neck or intertrochanteric fracture. Women with postoperative hemoglobin levels below 12.0 g/dL and men with levels below 13.0 g/dL were classified as having anemia. The main outcome measures were mortality, return to ambulatory ability, and return to activities of daily living at 3, 6, and 12 months. Hemoglobin data were available for 714 patients (85%). At time of last hemoglobin level measurement before discharge, 643 (90.1%) of the 714 patients were classified as having anemia. Patients who had sustained a femoral neck fracture that was treated with internal fixation were less likely to have anemia than were patients who had sustained a femoral neck fracture that was treated with hemiarthroplasty and patients who had sustained an intertrochanteric fracture (P < .001). Patients with anemia at the last discharge were not at increased risk for adverse outcomes at 3, 6, or 12 months compared with patients who did not have anemia

Hip fractures are common injuries in the elderly and are associated with considerable morbidity and mortality. Although technical advances in the treatment of the elderly have resulted in improved fracture fixation and surgical outcomes, clinical pathways have been developed to further improve patient outcome while shortening hospital length of stay after hip fracture. We describe the clinical pathway used since 1990 at the Hospital for Joint Diseases. The outcomes of 747 patients treated before 1990 were compared with outcomes of 318 patients treated at our hospital after initiation of the clinical pathway. Use of the clinical pathway was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and 1-year mortality

Background: Hip fracture is always a very traumatic event, especially for an older person. Often, it is followed by a marked decrease in the level of functioning a patient is able to achieve after recovery. It is even more debilitating when a previously independent person must be discharged to an institution. Objective: This study examined factors and trends associated with discharge to a skilled nursing facility following hip fracture surgery. Methods: Data were analyzed for 89,723 hip fracture patients admitted in New York State from 1986 to 1996. Factors examined included age, gender, race, type of fracture, surgical technique, comorbidities, length of hospitalization and year of admission. Results: Thirty-five percent (32,130) of the patients were discharged to skilled nursing facilities. They tended to be 85+ years old, female, white, have 3+ comorbidities, a history of dementia, have sustained an intertrochanteric fracture, and have been admitted after 1990. In addition, there was a gradual increase in institutionalizations after 1990. Conclusion: In this study, factors were found that predicted discharge to skilled nursing facilities following hip fracture.

Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year

The diagnosis of septic implant failure can be difficult to make, yet is imperative for optimal patient outcomes in revision total hip arthroplasty. In most cases, a thorough history and physical examination combined with preoperative laboratory tests and an intraoperative frozen section are sufficient to differentiate septic from aseptic failure. If preoperative laboratory test values are elevated, preoperative aspiration of the hip can be used in selected patients to confirm or exclude the diagnosis of infection. Nuclear medicine studies comprise a second-line investigation to evaluate patients with a painful total hip arthroplasty in whom revision surgery otherwise is not indicated. Intraoperative tissue appearance in combination with intraoperative Gram stains are unreliable for detecting periprosthetic sepsis, and neither is adequate when considered alone for ruling out infection at the time of revision total hip arthroplasty. It is imperative that the surgeon doing revision total hip arthroplasty thoroughly understands the relative utility of preoperative and intraoperative tests used to diagnose periprosthetic sepsis