Faculty Bibliography

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

The indications for glenohumeral arthroplasty are severe pain and restricted range of motion associated with radiographic evidence of advanced glenohumeral arthritis. Nonsurgical management consisting of rest, physical therapy, and antiinflammatory medication should be tried before considering surgical management. It is important that each patient be evaluated on the basis of the clinical disease and radiographic characteristics of the underlying diagnosis. Preoperative considerations should include a careful assessment of bone quality and quantity and associated deformity. Evaluation of the soft tissues, particularly the rotator cuff and deltoid muscles, is essential because the success of total shoulder arthroplasty depends greatly on the integrity of these structures. Associated upper and lower extremity degenerative arthritis should be evaluated and carefully considered, particularly with respect to the timing of surgical management. Careful consideration of these factors is invaluable in obtaining successful outcomes of total shoulder arthroplasty

Patients with a fracture of the proximal femur are at high risk for thromboembolic complications necessitating some form of preoperative and postoperative thromboembolic prophylaxis. Despite the knowledge that patients with a proximal femur fracture are at particularly high risk for both deep venous thrombosis and pulmonary embolism, there is no consensus on which strategy is most effective at preventing thromboembolic events in this patient population. The pathophysiology and associated risk factors for thromboembolic complications in this patient population are discussed. We present a review of studies that address the efficacy and safety of both mechanical and pharmacological methods of thromboembolic prophylaxis to assist the orthopedic surgeon in selecting among the different modalities available for thromboembolic prophylaxis

OBJECTIVE: To determine the effect of admission hemoglobin level on patient outcome after hip fracture. STUDY DESIGN: Prospective, consecutive. PATIENTS: From July 1991 to June 1997, 395 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed up. MAIN OUTCOME MEASUREMENTS: Postoperative complications, in-hospital mortality rate, hospital length of stay, hospital discharge status, place of residence at one year, and mortality and recovery of ambulatory ability and activities of daily living status at three, six, and twelve months. RESULTS: Women with admission hemoglobin levels below 12.0 grams per deciliter and men with admission hemoglobin levels below 13.0 grams per deciliter were classified as anemic. One hundred eighty patients (45.6 percent) were considered anemic on admission. Patients who were anemic were more likely to have an American Society of Anesthesiologists rating of III or IV and have sustained an intertrochanteric fracture. Hospital length of stay and mortality rate at six and twelve months were significantly higher for patients who were anemic on admission. There were no differences in the incidence of postoperative complications, hospital discharge status, place of residence at one year, in-hospital mortality rate, and three-month mortality rate between patients who were and were not anemic on admission. In addition, there were no differences in the recovery of ambulatory ability and of basic and instrumental activities of daily living status at three, six, and twelve months between the two patient groups. CONCLUSIONS: Patients at risk for poor outcomes after hip fracture can be identified by assessing hemoglobin levels at hospital admission

The reliability of combined indium-111 leukocyte/technetium-99m sulfur colloid scans, with and without the addition of blood pooling and blood flow studies, in the diagnosis of infected total joint arthroplasty was investigated. Both scans were performed on 58 patients before reoperation of total hip or knee arthroplasty in the period 1996-1999. Results for imaging alone included 100% specificity, 46% sensitivity, 100% positive predictive value, 84% negative predictive value, and 88% accuracy. Inclusion of blood pooling and flow phase data improved results to 66% sensitivity, 89% negative predictive value, and 90% accuracy, with reductions in specificity (98%) and positive predictive value (91%). Routine use of these radionuclide scans is not supported by these data

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 midterm results of primary posterior cruciate ligament-retaining, minimally conforming, cemented modular total knee arthroplasties using the Genesis I prosthesis in 110 knees in 72 patients were reviewed. Patients were evaluated at a mean follow-up of 7.3 years by Knee Society pain and functional scores, radiographic and survivorship analysis, and Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) health status questionnaire. Range of motion increased from an average of 96.3 degrees to 112.5 degrees. Knee Society pain and functional scores increased from preoperative averages of 55 and 44 to 92 and 88, respectively. There were 91 excellent, 16 good, 1 fair, and 2 poor results. WOMAC scores were increased significantly in each subcategory examined (pain, stiffness, and physical function). Kaplan-Meier survivorship was 97% at 10 years. An increase in loosening as a result of eccentric stress concentration secondary to the nonconforming design of this prosthesis, theoretically a matter of some clinical concern, was not shown in this investigation

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