Faculty Bibliography

We describe temporal and regional variation in hip fracture rates for people aged 65 or older in New York state (NYS) from 1985 to 1996. Our descriptive study was of all hip fracture cases admitted to NYS hospitals during that period. Case data were obtained from the Statewide Planning and Research Cooperative System (SPARCS) of the NYS Department of Health. US Census Bureau population estimates were obtained for each year from 1985 to 1996 to compute the annual hip fracture rate for each NYS county. These rates were adjusted for differences in age, gender, and race and were compared using logistic regression. Approximately 14,000 hip fractures occurred annually from 1985 to 1996. The annual rate (number of hip fractures per 1000 population) decreased from 6.4 in 1985 to 5.3 in 1996. White women aged 85 or older had the highest rate (26/1000); nonwhite men aged 65 to 69 had the lowest rate (<1/1000). Statewide annual rates decreased slightly over time, but this change was not reflected in all age, gender, and race subgroups. There was important, consistent variation in county rates after adjustment for age, gender, and race. Other researchers have identified geographic variation in national rates, but the postulated environmental and weather-related factors (eg, water fluoridation use; rainfall and sunshine amounts) have explained only a small proportion of this variation. Identification of risk factors that can better explain regional rate variation may lead to development of intervention strategies that could significantly reduce the risk for hip fracture among people 65 or older

BACKGROUND: The impact of strict enforcement of Section 405 of the New York State Public Health Code to restrict resident work to eighty hours per week and the adoption of a similar policy by the Accreditation Council on Graduate Medical Education in 2002 for orthopaedic residency training have not been evaluated. Adoption of these rules has created accreditation as well as staffing problems and has generated controversy in the surgical training community. The purposes of this study were (1) to evaluate the attitudes of orthopaedic residents and attending surgeons toward the Code 405 work-hour regulations and the effect of those regulations on the perceived quality of residency training, quality of life, and patient care and (2) to quantify the effect of the work-hour restrictions on the actual number of hours worked. METHODS: We administered a thirty-four-question Likert-style questionnaire to forty-eight orthopaedic surgery residents (postgraduate years [PGY]-2 through 5) and a similar twenty-nine-question Likert-style questionnaire to thirty-nine orthopaedic attending surgeons. All questionnaires were collected anonymously and analyzed. Additionally, resident work hours before and after strict enforcement of the Code 405 regulations were obtained from resident time sheets. RESULTS: The average weekly work hours decreased from 89.25 to 74.25 hours for PGY-2 residents and from 86.5 to 73.25 hours for PGY-3 residents, and they increased from 61.5 to 68.5 hours for PGY-4 residents. Residents at all levels felt that they had increased time available for reading. There was general agreement between attending and resident surgeons that their operating experience had been negatively impacted. Senior residents thought that their education had been negatively affected, while junior residents thought that their operating experience in general had been negatively affected. Senior residents and attending surgeons felt that continuity of care had been negatively impacted. All agreed that quality of life for the residents had improved and that residents were more rested. CONCLUSIONS: On the basis of the survey data, the implementation of the new work-hour restrictions was found to result in a decrease in the number of hours worked per week for PGY-2 and PGY-3 residents and in an increase in work hours for PGY-4 residents. This could explain the definite difference between the attitudes expressed by the senior residents and those of the junior residents. Senior residents felt that their education was negatively impacted by the work rules, while junior residents expressed a more neutral view. However, senior residents did not believe that their operative experience was as negatively impacted as did junior residents. Although junior and senior residents and attending surgeons agreed that resident quality of life had improved, we were not able to determine whether this offset the perceived negative impact on education, continuity of care, and operative experience

This study examined the effect of weather and seasonality on hipfracture incidence in older adults residing in New York City. A total off 66,346 patients aged > or = 65 years who sustained a fracture of the femoralneck or intertrochanteric region from 1985 to 1996 comprised the study population. Hip fractures were more likely to occur in the winter than in any of the other seasons (P<.001). Factors significantly correlated with hip fractureincluded minimum daily temperature (r=.167, P<.001), daily wind speed (r=.166, P<.001), maximum daily temperature (r=.155, P<.001), minutes of sunshine (r=.067, P<.01), and average relative humidity (r=.033, P=.03). A greater number of hip fractures occurred in colder months, withambient temperature rather than any adverse circumstances related to rainor snowfall associated most closely to injury. As most fractures occurredindoors, precipitation is less likely to play a part in hip fracture occurrence in this population

Hip fractures have been among the most studied injury patterns in adults. The number of hip fractures is increasing exponentially, and their treatment costs place great economic strain on society. Recently developed hip fracture treatments, emphasizing cost containment, deformity prevention, and evidence-based medicine, are attempts to optimize patient outcomes. In this article, we outline some of these developments with respect to femoral neck and intertrochanteric fractures

OBJECTIVE: To determine gender-specific differences in prefracture status and postoperative outcome in elderly hip fracture patients who were ambulatory, community-dwelling, and cognitively intact prior to fracture. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Urban orthopedic referral hospital. PATIENTS: A total of 983 consecutive patients (206 males and 777 females) who sustained a nonpathologic hip fracture were followed for a minimum of 12 months. INTERVENTION: Operative treatment of a proximal femur fracture. MAIN OUTCOME MEASUREMENTS: Postoperative medical complications, place of discharge, 1-year mortality, and postoperative recovery of ambulation, basic activities of daily living, and instrumental activities of daily living. RESULTS: Men were more likely to be married or living with someone else, and they were more dependent in instrumental activities of daily living than women prior to hip fracture. Furthermore, men were sicker as evidenced by a higher American Society of Anesthesiologists rating of preoperative risk. Postoperatively, men were more likely to sustain a medical complication and had a higher mortality at 1 year compared to women. There were no statistically significant gender differences in patient age, fracture type, prefracture level of help, ambulation, or dependence in basic activities of daily living, place of discharge, and postoperative recovery of ambulation as well as basic and instrumental activities of daily living. CONCLUSIONS: Male gender was a risk factor for sustaining a postoperative complication as well as a higher mortality at 1 year post hip fracture

Although the operative management of recurrent anterior glenohumeral instability has received significant attention in literature, the outcome of revision anterior shoulder repair is much less frequently reported. We report the results of our experience with this challenging problem. Retrospective chart review identified 29 patients who underwent revision anterior shoulder repair. Prior procedures included eight Bankart repairs, seven capsular shifts, 10 combined Bankart and capsular shift procedures, three Putti-Platt procedures, two staple capsulorrhaphies, two Bristow procedures, seven arthroscopie procedures, and one Magnuson-Stack. The average age of the patients was 31.6 years (range: 18 to 52 years) and the dominant extremity was involved in 69%. Findings at the time of revision anterior shoulder repair included 22 patients with capsulolabral detachment, 24 with capsular redundancy, and 14 with rotator interval defects. Twenty-three of the 29 patients were available for at least a two-year follow-up. Twenty-one (91%) remain stable. One patient was non-compliant with the postoperative immobilization and re-dislocated within the first month. The second patient, who had a prior Bankart procedure followed by a capsular shift two years later, underwent a capsular shift for significant capsular laxity. He re-dislocated approximately 15 months postoperatively. Our success rate of 91% in this small series approaches the results of primary open repair for recurrent glenohumeral instability. To achieve a successful outcome, it is essential to address all pathology at the time of revision repair

Humeral head replacement has been widely used for the treatment of complex proximal humeral fractures. The procedure is associated with a high rate of patient satisfaction as well as reliable relief of pain. The functional outcomes, however, have been variable. Reported complications include infection, neurologic injury, intraoperative fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. When technical factors such as tuberosity malunion or component malpositioning are considered as postoperative complications, the incidence of complications is relatively high. This high rate of complications, in turn, may be related to the wide range of reported functional outcomes

After its initial description by Neer and associates, humeral head replacement has been widely used to treat complex fractures of the proximal humerus. Many studies have confirmed that the treatment of proximal humeral fractures with humeral head replacement is associated with reliable pain relief as well as good patient satisfaction. A limited number of studies have also suggested that the prostheses have reasonable longevity, with the rate of prosthesis survival at 83% to 94% at 10 years. The functional outcome after the procedure, however, has not been as predictable. Using various outcomes scoring instruments, multiple studies have reported a wide range of results. Some authors have reported mostly disappointing outcomes, whereas others have reported generally satisfactory results. The most critical factor influencing the long-term outcome appears to be the position of the greater tuberosity. Other factors that are also associated with a good outcome include younger age, minimal delay between the traumatic event and the surgical procedure, and the absence of any neurologic deficit. For young patients with a complex proximal humeral fracture, humeral head replacement still remains a viable treatment option. However, whenever possible, most authors favor open reduction and internal fixation because of the issues affecting the longevity of the prosthesis. By understanding and minimizing the risk factors leading to a poor result, a reasonable functional outcome, reliable pain relief and a high rate of patient satisfaction can be expected after treatment of proximal humeral fractures with humeral head replacement