Faculty Bibliography

Recurrent instability in patients over forty years of age is felt to occur primarily as a result of an associated rotator cuff tear. This is often referred to as the 'posterior mechanism.' We reviewed our patients over the age of forty who underwent an anterior shoulder repair to identify the incidence of capsulolabral detachments and the role of an 'anterior mechanism' in this patient population. A retrospective review of all patients from 1985 to 2000 was performed to identify patients who had surgery for recurrent instability that began after forty years of age. Of the 265 patients records reviewed, 11 patients were identified who fulfilled the inclusion criteria. Of the 11 patients identified, 9 patients underwent anterior capsulolabral reconstruction for recurrent instability; the remaining two patients underwent repair of large rotator cuff tears. All 9 patients had a capsulolabral detachment, 4 had a rotator interval defect, 2 had anterior and inferior capsular redundancy, 1 had a small rotator cuff tear and 1 had an anterior capsular avulsion from the humeral head. At minimum follow-up of 32 months none of the patients reported episodes of instability. The reported incidence of rotator cuff tears in patients over the age of forty following an initial traumatic anterior glenohumeral dislocation ranges from 35% to 100%. When recurrent instability occurs, it is postulated to occur via a 'posterior mechanism' (i.e., secondary to a significant full-thickness rotator cuff tear). However, all of our patients had an anterior capsulolabral detachment as the 'common lesion' associated with recurrent instability. Although small, this series emphasizes the role of the 'anterior mechanism' in patients who develop recurrent instability after the age of forty. A high rate of success was achieved by addressing the pathoanatomic changes identified

Union of the greater tuberosity to the humeral shaft after hemiarthroplasty for acute fractures of the proximal humerus is a critical factor in the restoration of glenohumeral function. A retrospective review was undertaken to examine 23 consecutive patients who underwent hemiarthroplasty for the treatment of acute three- and four-part fractures of the proximal humerus. The study was conducted to examine the relationship between the position of the healed greater tuberosity and postoperative range of motion. The average age of the patients was 66.5 years. The average follow up was 3.8 years with a range of 24 to 108 months. Active range of motion was measured in forward elevation, external rotation, and internal rotation. Postoperative radiographs were examined to determine the position of the united greater tuberosity in relation to the top of the replaced humeral head. The tuberosity was fixed at an average of 15.4 mm below the top of the humeral head (range: 3 to 26 mm). A radiographic assessment of a control population of 50 normal proximal humeri demonstrated an average tuberosity position of 6.7 mm (range: 2 to 12 mm) below the superior aspect of the humeral head. Polynomial regression analysis demonstrated a polynomial relationship for active range of motion and tuberosity height. ANOVA testing demonstrated statistically significant differences in all ranges of motion. Active forward elevation for Group I (3 to 9 mm) was 88 degrees, Group 11 (10 to 16 mm) was 126 degrees, and Group III (17 to 26 mm) was 85 degrees (p = 0.04). Active external rotation for Group I was 19 degrees, Group II was 48 degrees, and Group III was 29 degrees (p = 0.01). Active internal rotation for Group I was to L2, Group II was to T10, and Group III was to L2 (p = 0.01). Although many factors affect the final ranges of motion in patients who undergo prosthetic replacement for acute proximal humeral fractures we believe that placement of the greater tuberosity 10 to 16 mm below the humeral head will assist in the maximum recovery of glenohumeral motion

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.