Faculty Bibliography

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

Recent studies have suggested that patients with a history of diabetes undergoing hip fracture stabilization have higher rates of morbidity and mortality as well as poorer functional results than control groups of non-diabetics. This study was performed to evaluate the effect of diabetes on patient outcome after hip fracture. Between July 1987 and December 1996, 849 community dwelling elderly who sustained an operatively treated hip fracture were prospectively followed to determine the effect of diabetes on patient outcome. The predictor variable was the presence or absence of diabetes mellitus. Ninety-three patients (11%) had a history of diabetes. Diabetic patients were more dependent in activities of daily living and ambulation prior to hip fracture. The presence of diabetes mellitus also increased the likelihood of a patient dying during hospitalization, but had no effect on recovery of ambulatory ability or activities of daily living. Although diabetic patients have increased in-hospital mortality when compared to non-diabetic patients, patients with diabetes are just as likely to recover pre-fracture functional status as non-diabetic patients

Variations in the shape and orientation of the anterior acromion have been implicated as predisposing factors for the development of rotator cuff problems. We determined and analyzed by computer digitization the anterior and posterior acromial slopes for 141 cadaver shoulders (whose rotator cuff status had been previously assessed). No significant differences in either the anterior or posterior angle were found between the intact and rotator cuff tear groups. Frequency histograms of both angles demonstrated continuous, normal distributions. The individual acromions were consistently asymmetric in that the anterior slope was larger than the posterior slope. However, the anterior slope distribution did not reveal groupings indicative of the specific acromial types previously reported. These results suggest that acromial classification into flat, curved, and hooked types does not accurately describe the actual anatomical findings

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

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

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

OBJECTIVE: To develop a Functional Recovery Score for ambulatory elderly hip fracture patients related to independent functioning to assess restoration of function to prefracture status. STUDY DESIGN/METHODS: The phases of this effort consisted of: (a) identification of five relevant components represented by sixteen specific functional capacities; (b) assessment of the importance independent community-dwelling elderly gave to the sixteen functional capacities; (c) pilot testing of a sixteen-item preliminary questionnaire in recovering elderly hip fracture patients; and (d) modification of the questionnaire to an eleven-item score. RESULTS: The resulting eleven-item Functional Recovery Score is comprised of three main components: basic activities of daily living (BADL) assessed by four items, instrumental activities of daily living (IADL) assessed by six items, and mobility assessed by one item. Basic activities of daily living comprise 44 percent of the score; instrumental activities of daily living comprise 23 percent, and mobility comprises 33 percent. Complete independence in basic and instrumental activities of daily living and mobility results in a score of 100 percent

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