Faculty Bibliography

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

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 these procedures were usually 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. Often successful in preventing recurrent instability, these earlier procedures also often led to a loss of external rotation, and consequently, function. Newer procedures that aim to prevent recurrent instability while maintaining full range of motion and function have been devised. Part I of this paper presents a brief history of the treatment of glenohumeral instability and a review of the literature, including the Bankart and du Toit procedures. Part II, which will be published in the December 1998 issue, includes the Putti-Platt, Magnuson-Stack, Bristow, and newer procedures

A detailed anatomic study of 123 shoulders was performed to define the location of the acromioclavicular (AC) joint within the supraspinatus outlet and to determine the correlation of AC joint morphologic characteristics with the presence of full-thickness rotator cuff tears (RCTs). The presence, location, and extent of RCTs were first documented for each shoulder, and 2 anatomic landmarks consisting of the anterolateral acromial corner and the inferior midpoint of the AC joint were identified and their positions digitized in 3 dimensions to calculate outlet space and clearance and AC joint locations. High resolution x-ray films were then obtained to determine the extent of degenerative changes including the location and size of inferior osteophytes and joint space. These specimens were cleaned of all soft tissues, and additional measurements were made. All data were entered into a computerized database and analyzed with respect to age, sex, and the presence of RCT. Comparison of age-matched RCT versus non-RCT groups revealed no significant differences in the position of the AC joint within the supraspinatus outlet. When AC joint morphologic characteristics were compared with those of a nontear, age-matched group, no significant differences with regard to joint space narrowing were found, but significantly larger and greater number of osteophytes were identified on both sides of the joint in the RCT group. In conclusion, the position of the AC joint is fairly constant within the supraspinatus outlet and does not appear to predispose to RCTs. The morphology of the AC joint contribution of the tears seems to be acquired in nature rather than inherent in its location within the outlet

Variations in the anatomic course of the cutaneous nerves about the lateral aspect of the elbow are important when surgical exposures and the establishment of arthroscopic portals are considered. The specific anatomic course taken by the lateral antebrachial cutaneous nerve and its relationship to the lateral epicondyle were determined by studying 33 upper extremities in 22 preserved adult cadavers. Considerable anatomic variation was found regarding the location of the lateral antebrachial cutaneous nerve as it crossed the elbow. The nerve pierced the brachial fascia an average of 3.2 cm proximal to the lateral epicondyle and was located an average of 4.5 cm medial to the lateral epicondyle as it crossed the interepicondylar line. In two instances, the nerve passed through the biceps muscle directly, prior to piercing the brachial fascia

Twenty uninjured male volunteers were studied to characterize normal elbow proprioception and to investigate the effect of applying an elastic bandage to the extremity and injection of an intraarticular anesthetic. A modified Biodex dynamometer was used to study position sense and detection of motion. In part 1 of the study position sense was tested by flexing the elbow to a predetermined angle, returning to the starting position, and then asking the subject to identify that angle. In part 2 detection of motion was tested by asking the subject to disengage the apparatus by pressing a stop button when movement was detected. The testing conditions in part 1 and part 2 were repeated after the elbow was wrapped with an elastic bandage and again after an intraarticular injection of 3 cc 1% lidocaine with the bandage removed. Ten additional subjects underwent testing of both elbows to examine the effect of arm dominance. Mean position sense was within 3.3 degrees+/-1.3 degrees of the actual angle in trials without an elastic bandage or an anesthetic. A significant improvement in position sense was observed (2.2 degrees+/-1.2 degrees) after an elastic bandage was applied (P < .004). No significant difference was seen in position sense after lidocaine was injected. The mean threshold for detection of motion in trials without an elastic bandage or an anesthetic was 4.21 degrees+/-1.56 degrees. No significant differences were seen in detection of motion observed with the elastic bandage or intraarticular anesthetic. No significant differences were seen between dominant and nondominant extremities for both position sense and detection of motion. The application of an elastic bandage improved position sense, suggesting that tactile cues from cutaneous or other extraarticular receptors may play a role in elbow proprioception. Intraarticular anesthesia, however, had little effect, suggesting that intracapsular receptors play a lesser role in elbow proprioception. The determination of proprioceptive qualities for the normal elbow can aid in the understanding of elbow function and provide a basis for defining its role in elbow dysfunction

The incidence of hip fractures worldwide is expected to almost quadruple in the next 60 years. Increased cost-containment pressures will focus attention not only on improvements in hip fracture treatment but also on prevention. Three approaches that can prevent hip fractures--preventing falls, preventing and treating bone fragility, and using external hip protectors--are reviewed. Although it is impossible to prevent all hip fractures, these methods may significantly reduce the annual incidence of these fractures