Faculty Bibliography

A 33-year-old male presented with acute onset of scapular winging following an injury to the shoulder girdle. A scapular osteochondroma was identified radiographically that was completely asymptomatic until the time of injury. Clinical presentation included the presence of a large exostosis bursata. Surgical resection of the osteochondroma resulted in resolution of all signs and symptoms

Unstable intertrochanteric hip fractures are characterized by comminution of the posteromedial cortex, resulting in a fragment of variable size containing the lesser trochanter. Controversy exists as to whether it is necessary to perform reduction and fixation of this fragment. This case lends further support to the practice of fixating the lesser trochanteric fragment in unstable intertrochanteric fractures

Total shoulder arthroplasty has become an effective treatment for advanced glenohumeral arthritis. The results depend, in part, on the underlying degenerative process. This article reviews the indications for glenohumeral arthroplasty, including important preoperative considerations. The different types of glenohumeral arthritides are discussed with respect to their clinical and radiographic manifestations, as well as their impact on preoperative planning

The problem of osteomyelitis has, to date, not been completely resolved. Recent research has provided additional insight into the pathogenesis of bone infection. Advances in pharmacology and in surgical techniques have enhanced our ability to treat such infections. Despite these advances, successful treatment of posttraumatic tibial osteomyelitis depends on adherence to several basic principles: complete debridement of necrotic and infected tissue, obtaining bony stability, the elimination of dead space, and the provision of durable soft tissue coverage. Armed with this new knowledge and surgical ability, treatment results have improved. We do not know, however, whether osteomyelitis can ever be 'cured,' since infections become manifest many years after injury or treatment

A prospective study was performed comparing modified Knowles pins to cannulated cancellous screws for the treatment of nondisplaced and impacted femoral neck fractures. Forty-five impacted or nondisplaced fractures were identified: twenty-five were stabilized with modified Knowles pins and twenty with cannulated cancellous screws. Patient follow-up averaged twenty-four months (range 12 to 46 months) or until reoperation. Six patients (13%) required reoperation; these failures were evenly divided between the two groups. The remainder of patients (twenty-two patients (88%) in the Knowles pin group and seventeen patients (85%) in the cannulated screw group) were comparable with regard to functional outcome

Palsy of the suprascapular nerve may be easily overlooked in the differential diagnosis of the painful shoulder. Although the diagnosis is well documented in the literature, opinion is still divided regarding its etiology and treatment. This case report offers an example of successful nonoperative management of a suprascapular nerve palsy which followed an acute episode of muscular stress in a young male athlete

The clinical efficacy of thromboprophylaxis with aspirin and dextran 40 was compared in a prospective review of 530 geriatric hip fracture patients treated surgically. All patients were also treated with early mobilization with weight bearing as tolerated and above-knee elastic stockings. In addition to clinical efficacy in preventing thromboembolic complications [deep vein thrombosis (DVT), pulmonary embolism (PE)], safety and cost-effectiveness were also assessed. The overall incidence of clinical thromboembolic disease was 2.8% (DVT = 0.4%, PE = 2.4%). The incidence of DVT (0.5%) and PE (2.6%) in the aspirin group was essentially the same as the incidence of DVT (0.3%) and PE (2.4%) in the dextran group. The inhospital mortality rate (aspirin 4.6%, dextran 3.8%), wound drainage (aspirin 1.5%, dextran 0.9%), deep wound infection (aspirin 0.5%, dextran 0.3%), gastrointestinal bleeding (aspirin 2.1%, dextran 1.5%), and congestive heart failure (aspirin 2.6%, dextran 1.8%) did not differ significantly between the two groups. The intraoperative transfusion rate was similar in both groups (aspirin .65 units, dextran .55 units). However, postoperatively, the transfusion rate was significantly higher in the dextran group (aspirin .26 units, dextran .41 units, p < .05). The treatment of thromboembolic complications was the same for each group and therefore represents similar treatment costs. However, the cost of prophylaxis with dextran was $309 per patient and with aspirin was $1.79 per patient. Our findings suggest that, based on clinical diagnostic criteria, aspirin and dextran are equally effective thromboembolic prophylactic agents in geriatric hip fracture patients. The safety, cost, and ease of administration of aspirin may make its use more desirable

We examined the effect of the Gamma nail on strain distribution in the proximal femur, using ten cadaver femora instrumented with six unidirectional strain gauges along the medial and lateral cortices. The femora were loaded to 1800 N and strains were determined with or without distal interlocking screws before and after experimentally created two-part and four-part fractures. Motion of the sliding screw and the nail was also determined. Strain patterns and screw motion were compared with previously obtained values for a sliding hip screw device (SHS). The Gamma nail was shown to transmit decreasing load to the calcar with decreasing fracture stability, such that virtually no strain on the bone was seen in four-part fractures with the posteromedial fragment removed; increasing compression was noted, however, at the proximal lateral cortex. Conversely, the SHS showed increased calcar compression with decreasing fracture stability. The insertion of distal interlocking screws did not change the pattern of proximal femoral strain. The Gamma nail imparts non-physiological strains to the proximal femur, probably because of its inherent stiffness. These strains may alter bone remodelling and interfere with healing. Distal interlocking screws may not be necessary for stable intertrochanteric fractures

The treatment of 25 tibias in 25 patients with posttraumatic chronic osteomyelitis was reviewed. The approaches to soft tissue management fell into three groups: 1) muscle flap coverage; 2) primary closure with suction irrigation; and 3) open cancellous bone grafting. Treatment success was judged by the presence or absence of drainage and the local signs or symptoms of infection, and by the status of the tibial nonunion. Overall, 19 of 25 tibias (76%) had successful treatment. We found flap coverage to have a higher success rate (80%) than either primary closure with suction irrigation (45.5%) or open cancellous bone grafting (40%). These results further attest to the refractory nature of chronic osteomyelitis

The care of geriatric patients who sustain hip fractures is difficult because of associated medical comorbidities, the risk of medical and surgical complications, and the functional limitations that are often present before the fracture. The authors developed and used a comprehensive, interdisciplinary care program that has so far treated 431 geriatric hip fracture patients. The results of the program group were compared to a matched nonprogram group of patients (n = 60) cared for before the initiation of the program (and before the initiation of diagnosis-related groups). The program patients had fewer postoperative complications, significantly fewer (p less than .05) intensive care unit transfers (10.2% versus 20%), significantly improved (p less than .001) ambulatory ability at discharge (56.3% independent with assistive devices versus 18.2%), and proportionately fewer discharges to nursing homes (8.1% versus 19.3%). These results support the use of an interdisciplinary approach as a means of improving the inhospital care of geriatric hip fracture patients