Faculty Bibliography

OBJECTIVE: To assess outcome after hip fracture in patients ninety years of age and older, as compared with a population of the same age and sex in the United States and younger patients with hip fractures. DESIGN: Prospective, consecutive. SETTING: University teaching hospital. METHODS: Eight hundred fifty community-dwelling elderly people who sustained an operatively treated hip fracture were prospectively followed up. MAIN OUTCOME MEASUREMENTS: The outcomes examined in this study were the patients' in-hospital mortality and postoperative complication rates, hospital length of stay, discharge status, mortality rate, place of residence, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery. RESULTS AND CONCLUSIONS: The mean patient age was 79.7 years (range 65 to 105 years). Seventy-six (8.9 percent) patients were ninety years of age and older. Patients who were ninety years of age and older had significantly longer mean hospital lengths of stay than younger individuals (p = 0.01). People ninety years of age and older were more likely to die during the hospital stay (p = 0.001) and within one year of surgery (p = 0.001). Patients who were ninety years of age and older were more likely to have a decrease in their basic activities of daily living status (p = 0.03) and ambulation level (p = 0.01). Younger individuals had a higher standard mortality ratio (1.48) than did patients who were ninety years of age and older (1.24). Being ninety years of age and older was not predictive of having a postoperative complication, of being placed in a skilled nursing facility at discharge or at one-year follow-up, or recovering of prefracture independence in instrumental activities of daily living

The changes that occur in the body as part of the normal aging process and the degenerative changes that often accompany them predispose the elderly to various orthopedic problems. Age, general health, and functional level are all important factors in determining the optimum management of these patients. Treatments are aimed at restoring patient independence and activity to preinjury levels, while at the same time minimizing the risks of treatment complications

OBJECTIVE: To evaluate the effect of previous cerebrovascular accident on outcome after hip fracture. STUDY DESIGN: Prospective, consecutive. PATIENTS: From July 1987 to March 1997, 862 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed. INTERVENTION: All patients had operative fracture treatment. MAIN OUTCOME MEASUREMENTS: Postoperative complications, in-hospital mortality, hospital length of stay, hospital discharge status, one-year mortality and place of residence, and return to preinjury ambulatory level, basic and instrumental activities of daily living status. RESULTS: Sixty-three patients (7.3 percent) had a history of cerebrovascular accident; the fracture was on the hemiplegic side in forty-six (86.8 percent) of the fifty-three patients with hemiplegia. Patients who had a history of cerebrovascular accident were more likely to be male and have an American Society of Anesthesiologists (ASA) rating of III or IV. They were also more likely to have three or more comorbidities, be a home ambulator, and be dependent on basic and instrumental activities of daily living before hip fracture. Hospital length of stay was significantly higher for patients who had a history of cerebrovascular accident. There were no differences in the incidence of hospital mortality or one-year mortality between patients who did and did not have a history of cerebrovascular accident before hip fracture. In addition, at one-year follow-up, when controlling for prefracture level of function, there were no differences in the rate of functional recovery between the two groups of patients. CONCLUSIONS: The functional recovery of elderly hip fracture patients who had a prior cerebrovascular accident was similar to that of patients who had no history of a prior cerebrovascular accident

A retrospective review was conducted on 15 cases of shoulder hemiarthroplasty performed for cuff tear arthropathy. All cases had advanced glenohumeral arthritis with complete supraspinatus and infraspinatus rupture and substantial involvement of the teres minor and subscapularis. The mean patient age was 73 years; the mean follow-up was 28.2 months. Range of motion, functional ability, pain relief, and overall patient satisfaction were assessed preoperatively and postoperatively. The average active forward elevation increased from 69 degrees to 86 degrees, and the average active external rotation increased from 15 degrees to 29 degrees. Thirteen patients had an increase in their ability to perform activities of daily living, 1 patient was unchanged, and 1 patient had a decrease in ability to perform activities of daily living. Pain relief was significantly improved in all but 1 patient. Eleven patients (13 of 15 shoulders, 87%) expressed an overall satisfaction with their surgery. Patients were assessed preoperatively and postoperatively through use of the UCLA Rating Scale; the average increase was 11 to 22 points. In addition, isokinetic strength testing was performed preoperatively and postoperatively on 6 of the 15 involved shoulders. An increase in peak torque in forward elevation, abduction, and external rotation was noted postoperatively. The findings of this study indicate that favorable clinical results can be obtained after hemiarthroplasty of the shoulder with associated massive rotator cuff deficiency

To evaluate the usefulness of the indium-111 scan in detecting actually or potentially infected total hip, knee, and resection arthroplasties, 153 scans were performed on 143 patients who underwent reoperation for a loose or painful total joint arthroplasty or a resection arthroplasty between 1990 and 1996. Scans were interpreted as infected, not infected, or equivocal by an experienced nuclear medicine radiologist. Patients were considered to be infected if they met any 2 of the following criteria: i) positive intraoperative cultures, ii) final permanent histologic section indicating acute inflammation, and iii) intraoperative findings of gross purulence within the joint. Twenty-six patients (17%) met the infection criteria at the time of reoperation. Indium scans were found to have a 77% sensitivity, 86% specificity, 54% and 95% positive and negative predictive values, and 84% accuracy for the prediction of infection. Of 6 equivocal scans, none were infected. The results of this study suggest limited indications for the use of the indium-111 scan in the evaluation of painful hip, knee, or resection arthroplasties. A negative indium scan may be helpful in suggesting the absence of infection in cases in which the diagnosis is not otherwise evident

Clinical and radiographic results of 116 patients who had undergone 132 hip arthroplasties at our institution from 1983 to 1988 with a collared cemented straight cobalt-chrome femoral stem using second-generation cementing technique were reviewed. Twenty hips in 20 patients who were part of the original cohort were lost to follow-up. Mean age at the time of surgery was 68.2 years. Mean radiographic follow-up was 9.6 years with a minimum follow-up of 5 years. Ten-year survivorship of the component was 96.5% with revision considered as an endpoint and 94.2% with either revision or radiographic loosening considered the endpoint. Three implants (2.3%) were revised for aseptic loosening at a mean of 8.1 years after implantation. One implant (0.8%) was revised for septic loosening at 10.5 years after surgery. Of the implants not revised, 1 showed evidence of circumferential bone-cement radiolucencies, and 1 had radiolucencies at the implant-cement interface. Five of the surviving femoral components (5.0%) showed focal areas of cystic osteolysis, and proximal femoral bone resorption under the collar was seen in 32 patients (31.7%). There were no cases of cement fracture or stem subsidence. The biomechanical and material properties of this stem combined with second-generation cementing technique look promising for long-term survivorship

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder. MATERIALS AND METHODS: From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography. RESULTS: SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography. CONCLUSION: MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon

OBJECTIVE: To assess predictive and discriminant validity and responsiveness of the Functional Recovery Score, a disease-specific health assessment tool. STUDY DESIGN: Prospective, consecutive. METHODS: Six hundred eighty-two elderly patients who sustained a hip fracture were prospectively followed and evaluated by using the Functional Recovery Score at three, six, and twelve months after surgery RESULTS: The Functional Recovery Score (FRS) was found to be responsive to change: scores after hip fracture were significantly lower at three months than prefracture, increased significantly from three to six months, and increased slightly between six and twelve months after fracture, consistent with expectation. The FRS had predictive validity: prefracture scores were predictive of death, skilled nursing facility transfer, and rehospitalization within one year of fracture. In addition, the FRS had discriminant validity. Mean scores for the following groups were significantly different from each other at three and six months: (a) patients who were alive, living in the community, and did not require rehospitalization; (b) those who were admitted to a skilled nursing facility; and (c) those who were rehospitalized. Comparison of the FRS with a sex- and age-matched non-hip-fracture population indicated that hip fracture resulted in a 20 percent loss of function within the first year. Reliability testing of telephone interviews of patients as a means of obtaining information indicated very high reliability. CONCLUSION: The Functional Recovery Score is a reliable method of assessing functional outcome for elderly hip fracture patients