Faculty Bibliography

BACKGROUND: There have been conflicting reports regarding the effect of the size of a tear of the rotator cuff on the ultimate functional outcome after repair of the rotator cuff. While some authors have reported that the size of the tear does not adversely affect the overall result of repair, others have reported that the outcome is less predictable after repair of a large tear than after repair of a small tear. The purpose of the present study was to examine the long-term functional outcome and the recovery of strength in thirty consecutive patients who had had repair of a large or massive tear of the rotator cuff. METHODS: Thirty consecutive patients who had operative repair of a large or massive chronic tear of the rotator cuff had a comprehensive isokinetic assessment of the strength of the shoulder preoperatively, twelve months postoperatively, and a mean of sixty-five months (range, forty-six to ninety-three months) postoperatively. The functional outcome was assessed with the University of California at Los Angeles shoulder score. RESULTS: All patients reported that they were satisfied with the result and had increased strength compared with preoperatively. There was a significant decrease in pain (p < 0.01) and significant improvements in function (p < 0.01) and the range of motion (p < 0.01). The mean University of California at Los Angeles shoulder score increased significantly from 12.3 points preoperatively to 31.0 points at the most recent follow-up examination (p < 0.01). The mean peak torque in flexion, abduction, and external rotation increased significantly to 80 percent (p < 0.01), 73 percent (p < 0.01), and 91 percent (p < 0.01), respectively, of that of the uninvolved shoulder by the time of the most recent follow-up examination. CONCLUSIONS: Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. The results of the present study suggest that more than one year is needed for complete restoration of strength. The strength of the affected shoulders still did not equal that of the unaffected, contralateral shoulders by the time of the long-term follow-up

Hip fractures, a significant cause of morbidity and mortality in the elderly, are expected to exponentially increase in frequency over the next 50 years as a result of increased life expectancy and population growth. The economic impact of the cost of hip fractures may be enormous. The overall cost of hip fractures includes not only death and illness, but also the costs of medical and custodial care, functional limitations, reduced quality of life, loss of independence, and inability to work, as well as other factors that are difficult to assess--most notably, the indirect effect of the hip fracture on the spouse or family members responsible for care. This review will evaluate the cost of geriatric hip fractures in the hopes of defining the enormous socioeconomic burden of such fractures

The ability to identify intraoperatively patients with an infected prosthesis at the time of a revision procedure assists the surgeon in selecting appropriate management. The results of 413 intraoperative Gram stains were compared with the results of operative cultures, permanent histology, and the surgeon's intraoperative assessment to determine the ability of Gram stains to identify periprosthetic infection. Gram staining correctly identified the presence of infection in 10 of the 68 cases that met study criteria for infection (sensitivity of 14.7%). Four false-positive Gram stains were encountered. Intraoperative Gram stains do not have adequate sensitivity to be helpful in identifying periprosthetic infection and should not be performed on a routine basis. They may be helpful, however, in cases in which gross purulence is encountered to assist in the selection of initial antibiotic therapy. The use of intraoperative Gram staining alone is inadequate for ruling out infection at the time of revision total joint arthroplasty

Twenty-one elbow dislocations with an associated radial head fracture were treated with immediate joint reduction, stabilization, and early range-of-motion exercises. In all cases initial treatment involved closed reduction of the ulnohumeral joint. For those cases involving minimally displaced and a few moderately displaced radial head fractures, treatment consisted of benign neglect (4 of 21). Of the more severely displaced fractures (17 of 21), 9 were treated with open-reduction internal fixation and 8 with immediate silicone head replacement. Despite radial head treatment, 6 of these cases remained unstable, prompting primary repair of collateral ligaments; 3 eventually required application of a hinged fixator as a salvage option. Results confirmed that initial radial head displacement predicts functional outcome. Our study demonstrates that fracture dislocations of the elbow demand a broad consideration of treatment options and that reconstruction of elbow stability requires either primary repair of collateral ligaments or the possible use of a hinged fixator device

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