Faculty Bibliography

Although AC pathology usually represents a late manifestation of outlet impingement, it typically presents as a cause of pain that is resistant to nonoperative and operative measures designed to treat purely anterior acromial pathology. The bursitis that occurs with AC joint impingement may be indistinguishable from anterior acromial impingement on clinical presentation; however, physical examination, diagnostic injection, and radiographic evaluation are generally sufficient to establish the diagnosis of AC joint impingement. Nonoperative measures are indicated for the treatment of acute bursitis, although operative intervention may be necessary in cases of large, distally projecting osteophytes in the presence of AC joint degeneration. Acromioclavicular pathology, when present, should be addressed at the time of subacromial decompression, and may involve distal clavicular resection, beveling of the AC joint, or excision of marginal osteophytes. The results of surgery to address the AC contribution to impingement are generally favorable; future investigation may further clarify the role of coplaning and its potential contribution to continued postoperative AC pain and symptomatic instability

In this article, we examine rates of in-hospital mortality of elderly patients with femoral neck fracture treated with internal fixation or hemiarthroplasty. Data were analyzed for 51,003 patients (> or = 65 years old) admitted with femoral neck fractures to New York state hospitals between 1985 and 1996. The primary outcome examined was in-hospital mortality. Associations between type of surgical procedure and outcome were assessed using a multiple logistic regression model, adjusting for patient age, sex, race, number of comorbidities, and residence in a nursing facility before hip fracture. Approximately 30% of the study group had undergone open or closed reduction and internal fixation; the other 70% had undergone hemiarthroplasty. Forty-six percent of the internal fixation group and 56% of the hemiarthroplasty group were 85 years old or older (P < .001). Median hospital stays were 13 days for the internal fixation group and 15 days for the hemiarthroplasty group (P < 001). In-hospital mortality was 5.1% overall, 3.9% for the internal fixation group, and 5.6% for the hemiarthroplasty group (P < .001). The association between type of procedure and mortality held after adjusting for patient age, sex, and number of comorbidities (odds ratio, 1.42; 95% confidence interval, 1.29-1.56; P < .001). After controlling for potential confounding variables, we found that elderly patients who had undergone hemiarthroplasty after femoral neck fracture were more likely to die during hospitalization than those who had undergone internal fixation

Proprioceptive ability was prospectively evaluated in patients with recurrent traumatic anterior instability who subsequently underwent anterior shoulder repair. Thirty consecutive patients were evaluated for passive position sense and detection of motion with the shoulder in flexion, abduction, and external rotation 1 week before surgery. They were then retested at 6 and 12 months postoperatively. A significant deficit in proprioception was found when the unstable side was compared with the uninvolved side before surgery. Six months after surgical repair, position sense showed an improvement of approximately 50% but was still found to be significantly different on the involved side; detection of motion was no longer significantly different from the uninvolved shoulder. One year after open anterior shoulder repair, both position sense and detection of motion were equivalent to those of the uninvolved shoulder

Rheumatoid arthritis affecting the shoulder region is a progressive disorder that results in pain, loss of range of motion, and functional disability. The inflammatory response, which is of unknown etiology, results in synovitis, pannus formation, and articular destruction. Even when patient history and physical examination suggest rheumatoid involvement of the shoulder, laboratory assessment and radiographic evaluation often are necessary to establish the diagnosis. Nonsurgical management is the primary treatment, including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability. Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief. The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues

OBJECTIVE: To determine the mortality risk following hip fracture and identify factors predictive of increased mortality. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care orthopaedic hospital. BACKGROUND: Approximately 250,000 hip fractures occur annually in the United States. The greatest mortality risk following hip fracture has been demonstrated to be within the first 6 months of fracture, and some studies report that the risk approaches expected mortality after 6 months. However, more recent studies have demonstrated that an increased risk of mortality may persist for several years postfracture. The purpose of this study was to assess the excess mortality associated with hip fracture at up to 2 years postinjury. METHODS: All patients with a hip fracture who were admitted to our institution over a 10-year period were evaluated. Criteria for inclusion included: Caucasian, age 65 or older, previously ambulatory, and home dwelling. Patients were followed prospectively to determine the mortality risk associated with hip fracture over a 2-year follow-up period. Mortality was compared to a standardized population and standardized mortality ratios were calculated. RESULTS: Eight hundred thirty-six patients met the inclusion criteria and were included. The mortality risk was highest within the first 3 months following fracture, with standardized mortality ratios approaching that of the control population by two years. Patients age 65-84 had higher mortality risk when compared with patients age > or =85. American Society of Anesthesiologists classification was predictive of increased mortality risk in younger patients, with these patients having triple the mortality risk when compared to the reference population at 2-year follow-up. More elderly patients had minimal excess mortality associated with hip fracture at 1- and 2-year follow-up, regardless of ASA classification. CONCLUSION: The data demonstrate that hip fracture is not associated with significant excess mortality amongst patients older than age 85. Amongst younger patients, however, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury

The size and shape of the suprascapular notch may be a factor in suprascapular nerve entrapment. The suprascapular notches of 623 scapulae were digitally photographed and used to determine notch type and area. Three researchers used to different classification systems for suprascapular notch typing. These systems were compared for interobserver reliability and intraobserver reproducibility using the kappa test. The mean kappa value for the classification used by Rengachary and colleagues was 0.468 and for the classification used by Ticker and associates was 0.531 for the inferior border of the notch and 0.736 for the superior border of the notch. The classification system used by Ticker and associates was more reliable and reproducible and produced both a superior and an inferior classification, making it possibly more clinically relevant than the classification system used by Rengachary and colleagues

The glenoids of 412 scapula specimens were templated with the use of 6 currently available glenoid systems to determine the goodness of fit for the various designs. When a fitting criterion of a mismatch of less than 2 mm between the template and the actual glenoid periphery for 8 radial locations was used, the various designs fit from 0% to 48% of the glenoids. Because glenoid component fixation longevity can depend on the degree of osseous support, these results indicate that glenoid component design and sizing can be improved

Allergy to polymethyl methacrylate bone-cement or its components is unusual. Because of the potential for an inflammatory response in an allergic patient and the possibility of pain and loosening if a cemented implant is used, it is imperative to identify patients with this allergy to modify their treatment. We report the case of an otherwise healthy 60-year-old woman who needed a total knee arthroplasty and who had an allergy to methyl methacrylate bone-cement identified preoperatively. The appropriate evaluation for a patient who is suspected to have an allergy to bone-cement or its components is reviewed