Faculty Bibliography

Three hundred thirty-eight community dwelling, ambulatory, elderly patients who sustained a hip fracture were observed prospectively to determine which patient and fracture characteristics at hospital admission predicted functional recovery at 3, 6, and 12 months. Multiple logistic regression was performed to estimate the simultaneous contributions of the predictor variables to failure of functional recovery. Before sustaining a fracture, 16% of patients were dependent on basic activities of daily living and 46% were dependent on instrumental activities of daily living. By 1 year after fracture, 73% of the patients had recovered to their basic activities of daily living status before fracture whereas only 48% had recovered to their instrumental activities of daily living status before fracture. Patients who were age 85 years or older, who lived alone before sustaining a fracture, and who had one or more comorbidities were at increased risk of delay or failure in recovering basic activities of daily living. Only instrumental activities of daily living independence before fracture predicted failure to recover instrumental activities of daily living function by 3 and 6 months after fracture. At 1 year, patient age 85 years or older was the only predictor of failure to recover instrumental activities of daily living function that existed before fracture. Based on characteristics at admission, a group of patients at high risk for failure to recover basic activities of daily living function within 1 year of sustaining a hip fracture can be identified

The effect of anesthetic technique on ambulation and functional recovery after hip fracture was studied in a series of 631 community dwelling, elderly patients. Functional recovery at followup was determined by an 11-item functional rating scale. In univariate analysis, recovery of ambulatory ability and percent functional recovery were significantly higher at 6 months for patients who had general anesthesia. When controlling for potential confounding variables, however, no differences were observed in recovery of ambulatory ability or percent functional recovery between the two groups at 3, 6, or 12 months after hip fracture

A study was performed to assess the impact of intensive inpatient rehabilitation on the outcome after a fracture of the femoral neck or an intertrochanteric fracture. Before 1990, our hospital did not have an inpatient rehabilitation program. On January 1, 1990, a diagnosis-related-group-exempt (DRG-exempt) acute rehabilitation program was initiated. Patients were discharged to this program after evaluation by a staff physiatrist. Before 1990, twenty-seven (9.0 per cent) of 301 patients were discharged to an outside rehabilitation facility. After January 1990, the percentage of patients who were discharged to the DRG-exempt program increased yearly, from nineteen (17 per cent) of 113 patients in 1990 to forty-one (64 per cent) of sixty-four patients in 1993; this difference was significant (p < 0.01). Before 1990, the average duration of the stay in the hospital was 21.9 days. After January 1990, the average duration for the patients who did not enter the rehabilitation program was 20.0 days whereas the average duration for those who did was 31.4 days (16.1 days for acute care and 15.6 days for the rehabilitation program). There were no differences in the hospital discharge status or in the walking ability, place of residence, need for home assistance, or independence in basic and instrumental activities of daily living at the six and twelve-month follow-up examinations between patients who had been managed before initiation of the rehabilitation program and those managed after it or between patients who had been discharged to this program after its initiation and those who had not. These results raise serious questions regarding the global cost-effectiveness of these programs for patients who have had a fracture of the femoral neck or an intertrochanteric fracture

Rheumatoid arthritis of the glenohumeral joint can produce significant pain and disability that interferes with the ability to perform even the basic activities of daily living. In this article the authors discuss the epidemiologic aspects of rheumatoid arthritis, the pathologic condition as it affects the shoulder complex (consisting of the glenohumeral, acromioclavicular, and sternoclavicular joints), the differential diagnosis, clinical and radiographic manifestations, and treatment approaches designed to maintain or regain function

The operative management (open versus arthroscopic) of subacromial impingement was investigated through a search of the English-language literature from 1970 to 1996. Thirty-four clinical studies comprising 1,935 patients met the following selection criteria: a study published in a peer reviewed journal, a valid materials and methods section (describing age, gender, number of subjects, follow-up period, treatment modality, and impingement stage), and acromioplasty without rotator cuff repair. Six hundred and ninety-eight patients had an open decompression (OD) and 1,237 had an arthroscopic subacromial decompression (ASD) for Stage II and III impingement. When possible, only Stage II patients were reviewed. A few studies combined Stage II and III patients in their results; thus, the patients were placed into two groups (OD and ASD) composed of four categories: OD of Stage II impingement (494 patients), OD of Stage II and III impingement (204 patients), ASD of Stage II impingement (727 patients), and ASD of Stage II and III impingement (510 patients). The average duration of symptoms before surgery ranged from 6 months to 43 months in the OD group and 6 months to 61 months in the ASD group. The average age was 41.8 and 42.1 years, clinical follow-up 6 months to 62 months and 12 months to 41 months in the OD and ASD groups, respectively. The objective success rates were 83.3% versus 81.4% and the subjective success rates were 90.0% versus 89.3% for OD versus ASD, respectively. Return to work ranged from 43% to 100% in the OD group and 74% to 100% in the ASD group. Based on our review, the outcome from ASD is similar to OD. For persistent stage II primary impingement, we recommend starting with ASD and reserve OD for surgical failures. ASD allows earlier rehabilitation than OD because complete detachment of the deltoid is not performed, yet ASD is technically more demanding and has a long learning curve