Faculty Bibliography

The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the elbow. This form was developed by the Research Committee of the American Shoulder and Elbow Surgeons and subsequently adopted by the membership. The patient self-evaluation section contains visual analog scales for pain and a series of questions relating to function of the extremity. The responses to the questions are scored on a 4-point ordinal scale. The physician assessment section has 4 parts: motion, stability, strength, and physical findings. It is hoped that adoption of this method of data collection will stimulate multicenter studies and improve communication between professionals who assess and treat patients with elbow disorders

BACKGROUND: Despite the effectiveness of a two-stage exchange protocol for the treatment of deep periprosthetic infection, infection can persist after resection arthroplasty and treatment with antibiotics, leading to a failed second-stage reconstruction. Intraoperative analysis of frozen sections has been shown to have a high sensitivity and specificity for the identification of infection at the time of revision arthroplasty; however, the usefulness of this test at the time of reoperation after resection arthroplasty and treatment with antibiotics is, to our knowledge, unknown. METHODS: The medical records of sixty-four consecutive patients who had had a resection arthroplasty of either the knee (thirty-three patients) or the hip (thirty-one patients) and had had intraoperative analysis of frozen sections of periprosthetic tissue obtained at the time of a second-stage operation were reviewed. The mean interval between the resection arthroplasty and the attempted reimplantation was nineteen weeks. The results of the intraoperative analysis of the frozen sections were compared with those of analysis of permanent histological sections of the same tissues and with those of intraoperative cultures of specimens obtained from within the joint. The findings of the analyses of the frozen sections and the permanent histological sections were considered to be consistent with acute inflammation and infection if a mean of ten polymorphonuclear leukocytes or more per high-power field (forty times magnification) were seen in the five most cellular areas. RESULTS: The intraoperative frozen sections of the specimens from two patients (one of whom was considered to have a persistent infection) met the criteria for acute inflammation. Four patients were considered to have a persistent infection on the basis of positive intraoperative cultures or permanent histological sections. Overall, intraoperative analysis of frozen sections at the time of reimplantation after resection arthroplasty had a sensitivity of 25 percent (detection of one of four persistent infections), a specificity of 98 percent, a positive predictive value of 50 percent (one of two), a negative predictive value of 95 percent, and an accuracy of 94 percent. CONCLUSIONS: A negative finding on intraoperative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; however, the sensitivity of the test for the detection of persistent infection is poor

OBJECTIVES: This study was performed to determine whether four cancellous lag screws provide significantly improved rigidity and fixation strength compared with three screws for fixation of displaced femoral neck fractures with posterior comminution. DESIGN: Biomechanical cadaver study. INTERVENTION: Eight pairs of mildly osteopenic femurs were selected, and each pair was fixed with three or four cancellous lag screws (randomly assigned) after the creation of a simulated femoral neck fracture with posterior comminution. A separate comparison with an unmatched group of six similar femurs with a simulated femoral neck fracture without posterior comminution and instrumented with three screws was performed to investigate the effect of posterior comminution. MAIN OUTCOME MEASUREMENT: The specimens were non-destructively tested to determine fixation rigidity in axial and anterior loading. Cyclic axial loading was then performed for 10,000 cycles; the femurs were retested for rigidity and finally were axially loaded until failure. RESULTS: The femurs with a posterior defect stabilized with three screws had significantly less resistance to axial and anterior displacement and sustained significantly lower axial loads to failure than those stabilized with four screws. The specimens instrumented with three screws without a posterior defect exhibited greater resistance to displacement in anterior loading and sustained greater axial loads to failure than those with a posterior defect stabilized with three screws. CONCLUSION: This study suggests that there are benefits to using four screws for fixation of femoral neck fractures with posterior comminution

OBJECTIVE: To determine the effect of nutrition on patient outcome after hip fracture. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Four hundred ninety hip fracture patients had albumin and total lymphocyte count levels determined at the time of admission and constituted the study population. These variables were examined as predictors for outcomes, including: in-hospital mortality, postoperative complications, hospital length of stay, hospital discharge status, one-year mortality rate, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery. RESULTS: Eighty-seven patients (18 percent) were found to be malnourished on hospital admission based on a preoperative albumin level of < 3.5 grams/deciliter, and 280 patients (57 percent) based on a total lymphocyte count of < 1,500 cells/milliliter. An albumin level of < 3.5 grams/deciliter was predictive for increased length of stay (p = 0.03) and for in-hospital mortality (p = 0.03). A total lymphocyte count < 1,500 cells/milliliter was predictive for one-year mortality (p < 0.01). Patients with abnormal albumin and total lymphocyte count were 2.9 times more likely to have a length of stay greater than two weeks (p = 0.03), 3.9 times more likely to die within one year after surgery (p = 0.02), and 4.6 times less likely to recover their prefracture level of independence in basic activities of daily living (p < 0.01). Neither parameter was predictive for patients developing a postoperative complication, hospital discharge status (home versus nursing home), recovery of prefracture ambulatory ability, or independence in instrumental activities of daily living at twelve-month follow-up. CONCLUSION: Patients at risk for poor outcomes after hip fracture can be identified using relatively inexpensive laboratory tests such as albumin and total lymphocyte count

Although most fractures of the proximal femur result from a fall and are related to direct loads to the hip, there is evidence that intrinsic factors, such as muscle contraction, can result in a hip fracture and subsequent fall. This paper reviews the current literature on the various mechanisms of femoral neck and intertrochanteric fractures

Seven hundred forty-nine community-dwelling, previously ambulatory, elderly patients who sustained a femoral neck or intertrochanteric fracture underwent prospective follow-up to determine whether anesthetic technique (spinal or general) had an effect on inpatient morbidity and mortality, or 1-year mortality. One hundred seven patients were excluded from the study as the anesthetic technique was 'predetermined' based on a underlying medical condition. Of the remaining 642 patients, 362 (56.4%) received general and 280 (43.6%) received spinal anesthesia. Twenty (3.1%) patients died during hospitalization; 73 (11.4%) patients developed one or more postoperative medical complications. The 1-year mortality rate was 12.1%. There was no difference in inpatient morbidity and mortality, or 1-year mortality rates between patients receiving general or spinal anesthesia

The purpose of this study was to investigate the effect of age, dominance, joint position, and lidocaine injection on proprioception of the normal shoulder. Position sense and the detection of passive shoulder motion were investigated in 40 young (20 to 30 years) and old (50 to 70 years) subjects. An additional 20 young subjects were tested before and after a glenohumeral (n = 10) or a subacromial (n = 10) lidocaine injection was performed. A significant decline occurred in proprioception between the young and old age groups. No difference was observed between dominant and nondominant sides. Position sense was consistently less accurate in the maximum range of motion tested when compared with the lesser ranges tested for flexion and abduction. No differences were identified in the ability to detect motion in flexion, abduction, and external rotation in the younger group, whereas in the older group a difference was observed in flexion. No learning effect was detected for any test trial. No significant changes occurred in proprioceptive ability after either glenohumeral or subacromial lidocaine injection was performed

The clinical and radiographic results of 86 primary total hip arthroplasties performed in 74 patients from 1983 to 1987 with a cemented metal-backed acetabular component and a cemented collared straight femoral stem with a 32-mm head were reviewed at a mean follow-up of 10.1 years. Seven patients (9.2%) underwent acetabular component revision at a mean of 9.0 years after implantation; an additional 24 components (31.6%) demonstrated evidence of radiographic loosening, resulting in a total failure rate of 40.8%. Periacetabular radiolucencies were noted in Charnley zones at the following rates: 34.2% in zone I, 18.4% in zone II, and 27.6% in zone III. In addition, 18.4% and 38.2% of implants demonstrated evidence of migration and excessive polyethylene wear. Excessively vertical cup placement (>49 degrees inclination) at the time of initial arthroplasty was statistically correlated with polyethylene wear, implant migration, and fixation failure. A trend of increasing implant failure was also noted with decreasing polyethylene liner thickness. Periacetabular cement mantle thickness was not statistically correlated with subsequent component loosening or failure. Results of Kaplan-Meier survivorship analysis using revision as an endpoint showed 93.6% survivorship at 10 years and 88.4% at 12 years. The mean modified Harris hip scores were 46.9 preoperatively and 81.8 at final follow-up. The significant overall rates of radiographic loosening, migration, polyethylene wear, and implant revision confirm the suspected trend of increasing failure rates of cemented metal-backed acetabular components over time

Anterior glenohumeral instability is an undesirable result of trauma to the shoulder. Several surgical treatments for this condition have been developed, beginning in the early years of the twentieth century. Although many of these procedures were popular at their inception, many of them have fallen out of favor as more information has been acquired concerning the long-term results and complications of their use. While often successful in preventing recurrent instability, these earlier procedures also often led to a loss of external rotation, and consequently, function. Newer procedures have been devised that aim to prevent recurrent instability while maintaining full range of motion and function. Part I of this paper, published in the November issue, presented a brief history of the treatment of glenohumeral instability and a review of the literature, including the Bankart and du Toit procedures. Part II includes the Putti-Platt, the Magnuson-Stack, the Bristow, and capsular shift procedures