Faculty Bibliography

OBJECTIVE: To determine the one year mortality following hip fracture in an ambulatory, community dwelling, cognitively intact elderly population and to examine the role of specific type, number, and severity of associated medical comorbidities. DESIGN: Prospective, consecutive. METHODS: Six hundred twelve elderly who sustained a non-pathologic hip fracture were followed. RESULTS: Twenty-four patients (4%) died during hospitalization; seventy-eight (12.7%) died within one year of fracture. The factors that were predictive of mortality, based on multivariate analysis, were patient age > 85 years, preinjury dependency in basic activities of daily living, a history of malignancy other than skin cancer, American Society of Anesthesiologists rating of operative risk 3 or 4, and the development of one or more in-hospital postoperative complications; all factors other than the development of an in-hospital complication were independent of treatment. CONCLUSION: These results indicate that efforts at reducing one year mortality after hip fracture should be directed at the prevention of postoperative complications

OBJECTIVE: To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection. STUDY DESIGN: Prospective, consecutive. METHODS: Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics. RESULTS: Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant. CONCLUSIONS: Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused

One hundred ten acromial anatomic specimens were classified by three shoulder surgeons with the classification system described by Bigliani et al. to determine the interobserver reliability. These results demonstrated a fair to poor level of interobserver reliability. Given this relatively low level of agreement, the diagnosis of impingement and rotator cuff tears should be based on clinical findings supplemented, when indicated, by rotatory cuff imaging with less diagnostic reliance placed on the assessment of acromial morphology

Twenty-six patients with Grade III acromioclavicular joint separations were evaluated to determine the outcomes of nonoperative and operative management. Evaluation consisted of a detailed functional questionnaire, physical examination, and comprehensive isokinetic strength assessment. The patients were divided into two groups: operative (n = 16) and nonoperative (n = 10). Operative management consisted of coracoclavicular stabilization with heavy suture material and with nine of the sixteen patients treatment also consisted of coracoacromial ligament transfer and lateral clavicle resection. Nonoperative management consisted of short-term immobilization with early range of motion and rehabilitation. The two groups were similar in all characteristics except mean age: 30.7 years for the operative group and 49.6 years for the nonoperative group. Follow-up evaluation was performed an average of 32.9 months after either injury (nonoperative group) or surgery. Our results indicated that nonoperative management was superior to operative management with respect to time to return to work (0.8 months vs. 2.6 months), time to return to athletics (3.5 months vs. 6.4 months) and time of immobilization (2.7 weeks vs. 6.2 weeks). However, operative management was superior to nonoperative management in the following parameters: time to attain completely pain-free status, the patient's subjective impression of pain, range of motion, functional limitations, cosmesis, and long-term satisfaction. There were no significant differences between the two groups with respect to shoulder range of motion, manual muscle testing, or neurovascular findings. Isokinetic strength testing of the involved shoulder, expressed as a percentage of the uninvolved shoulder, showed no significant differences in peak torque, total work, or total power between the operative and nonoperative groups. However, comparison of the involved to the uninvolved extremity within each group did reveal a trend toward decreased peak torque, work, and power for abduction in the involved extremity regardless of the treatment used. These findings reached statistical significance only for power at the slower testing speed (60 degrees/sec). There was also a significant decrease in power in the involved extremity for external rotation at the faster speed (120 degrees/sec) in the nonoperative group. Finally, the absolute values for peak torque, work, and power were significantly greater for all motions tested in the operative group as compared to the nonoperative group. This may reflect the difference in age between the two groups. Based upon the patients studied, there are benefits to both nonoperative and operative methods of treatment of Grade III acromioclavicular separations. Recovery of strength did not differ between the two groups and therefore should be viewed as a less important factor in patient selection for operative versus nonoperative management. Careful patient selection should remain an important aspect of treatment for this controversial injury

The strength of active flexion/extension and supination/pronation was measured isokinetically in 60 right-hand-dominant nonathletic men. They were equally divided into a younger group (20 to 30 years) and an older group (50 to 60 years) with moderate occupational and spare-time activity levels. Peak torque, work, power, and the angle of peak torque production were measured bilaterally at a slow (90 degrees/sec) and a fast (180 degrees/sec) speed of movement. Although highly significant differences were found between the young and older groups in flexion and extension, no age-related differences were found in supination and pronation. The dominant side had significantly higher levels of peak torque, work, and power in flexion; however, no significant differences were detected in peak torque for extension, supination, and pronation. Isokinetic peak torque and work were greater at the slower speed as opposed to power, which was significantly greater at the faster speed with the exception of pronation movement. With regard to the angle where peak torque was achieved, significant differences were detected between groups, which suggests that age appears to affect where in the range of motion peak torque is produced