Faculty Bibliography

Our hospital implemented an integrated cost-containment program designed to address the increasing disparity between the cost of orthopaedic implants used for total joint replacements and the amount of hospital reimbursement provided for these procedures. This program was divided into four phases: (1) the analysis of the specific usage of total hip and total knee implants at our institution, (2) the development of surgeons' awareness of the problem and the enlistment of their participation in the process of cost containment, (3) the initiation of a competitive bidding system to select standard prostheses that would be available for general use within the institution, and (4) the establishment of a prosthesis-utilization committee to monitor the process and to make decisions concerning the use of non-standard prostheses. Using this cost-containment program, our hospital greatly reduced the number of vendors and implant systems used; all implants were purchased on a consignment basis, which minimized the cost of implant inventory. The average cost reductions in the first year were 14 per cent for total hip implants and 24 per cent for total knee implants. Over-all implant costs were reduced by an estimated $706,477, or 23 per cent of the budget for implants for the previous year

Hip fractures remain a major source of morbidity and mortality in the elderly, and their incidence is increasing as the population ages. Surgical management followed by early mobilization is the treatment of choice for most patients with hip fractures. However, all comorbid medical conditions, particularly cardiopulmonary and fluid- electrolyte imbalances, must be evaluated and stabilized prior to operative intervention. Nondisplaced femoral-neck fractures should be stabilized with multiple parallel lag screws or pins. The treatment of displaced femoral-neck fractures is based on the patient's age and activity level: young active patients should undergo open reduction and internal fixation; older, less active patients are usually treated with hemiarthroplasty, either uncemented or cemented. Regardless of treatment method, the goal is to return the patient to his or her prefracture level of function

Surgical stabilization followed by early mobilization is the treatment of choice for both nondisplaced and displaced intertrochanteric fractures. Fracture stability is dependent on the status of the posteromedial cortex. The sliding hip screw is the device mostly commonly used for fracture stabilization. The most important aspect of its insertion is secure placement within the femoral head. Although the sliding hip screw allows postoperative fracture impaction, it is essential to obtain an impacted reduction at the time of surgery. If there is a large posteromedial fragment, an attempt should be made to internally fix the fragment with a lag screw or cerclage wire. Although intramedullary hip screws have not been shown to be superior to the sliding hip screw, they may have selected indications

Trauma series radiographs of 50 proximal humerus fractures were used to assess the relative contribution of the scapular lateral and axillary radiographs to fracture classification with the Neer system. The radiographs were reviewed by an orthopaedic shoulder specialist, on orthopaedic traumatologist, a skeletal radiologist, and orthopaedic residents in their fifth and second years, respectively, of postgraduate training. In the first viewing radiographs were reviewed and classified in the following sequence: (1) after scapular anteroposterior view alone; (2) after review of scapular anteroposterior and lateral views; and (3) after review of scapular anteroposterior, lateral, and axillary views. A second viewing of the same 50 cases was performed 6 months later in a changed sequence: (1) after scapular anteroposterior view alone; (2) after review of scapular anteroposterior and axillary views; and (3) after review of scapular anteroposterior, axillary, and scapular lateral views. For the five observers, review of the scapular anteroposterior and axillary views achieved the final classification in 99% of cases. However, after review of the scapular anteroposterior and lateral views, the final classification was achieved in only 79% of cases (p < 0.05). These results indicate that when combined with the scapular anteroposterior radiograph, the axillary view contributes significantly more to fracture classification with the Neer system than the scapular lateral radiograph.

The radiographs of fifty fractures of the proximal part of the humerus were used to assess the interobserver reliability and intraobserver reproducibility of the Neer classification system. A trauma series consisting of scapular anteroposterior, scapular lateral, and axillary radiographs was available for each fracture. The radiographs were reviewed by an orthopaedic shoulder specialist, an orthopaedic traumatologist, a skeletal radiologist, and two orthopaedic residents, in their fifth and second years of postgraduate training. The radiographs were reviewed on two different occasions, six months apart. Interobserver reliability was assessed by comparison of the fracture classifications determined by the five observers. Intraobserver reproducibility was evaluated by comparison of the classifications determined by each observer on the first and second viewings. Kappa (kappa) reliability coefficients were used. All five observers agreed on the final classification for 32 and 30 per cent of the fractures on the first and second viewings, respectively. Paired comparisons between the five observers showed a mean reliability coefficient of 0.48 (range, 0.43 to 0.58) for the first viewing and 0.52 (range, 0.37 to 0.62) for the second viewing. The attending physicians obtained a slightly higher kappa value than the orthopaedic residents (0.52 compared with 0.48). Reproducibility ranged from 0.83 (the shoulder specialist) to 0.50 (the skeletal radiologist), with a mean of 0.66. Simplification of the Neer classification system, from sixteen categories to six more general categories based on fracture type, did not significantly improve either interobserver reliability or intraobserver reproducibility

In conclusion, the clinical picture of impingement syndrome is one of a continuum occurring as a result of compression of the bursa and rotator cuff within the subacromial space. In its early stages nonoperative management will often suffice, but in resistant cases and in cuff tears operative intervention is often indicated. The usefulness of MR imaging has greatly expanded for the orthopaedist diagnosing and treating the patient with impingement. After careful clinical evaluation and plain radiographs, MR imaging can significantly add to our knowledge as to the extent of the disease process. This added information can aid in tailoring an individualized treatment regimen and can be invaluable in the preoperative planning for patients with rotator cuff pathology

There are 23 cases in the literature of fracture table-induced pudendal nerve palsy. The majority of these patients had full sensory return; however, return of sexual function was unpredictable. The relevant anatomy, etiology, and incidence of this complication are discussed, and suggestions are made for its prevention