Faculty Bibliography

No doubt all experienced clinicians have observed cases in which a hip fracture dramatically diminished the independence and quality of life of an elderly person. This difficult problem requires a concentrated, multidisciplinary effort. More than 800 patients have now been treated using our interdisciplinary approach. A recent review of the data shows that results in this larger group compare favorably with those in the followup group described in this article. We believe that our approach shows promise as a model for the future. Further, comparisons with current practices may lead in some situations to significant improvements in hip fracture rehabilitation. Primary care physicians play a key role in this process of review and modification and in contributing to the overall restorative effort

Two hundred fifty consecutive intertrochanteric fractures treated with a sliding hip screw (SHS) over a three year period were reviewed and specific types of technical pitfalls identified. Most pitfalls were technique dependent and potentially preventable with proper attention to the principles of fracture reduction and insertion of the device. Pitfalls encountered with the use of the SHS occurred as a result of either poor fracture reduction or implant insertion. Problems related to fracture reduction included poor radiographic visualization, posterior sag, varus angulation, and internal rotation of the femoral shaft in relation to the femoral neck. Potential pitfalls encountered during SHS insertion included superior guide wire placement, guide wire breakage or penetration into the hip joint or pelvis, loss of reduction during lag screw insertion, improper screw-barrel relationship, and improper plate application. Finally, the SHS may not be the implant of choice for all extracapsular hip fractures (i.e., the reverse obliquity fracture). This paper identifies the various pitfalls that may occur with the use of the SHS for the fixation of intertrochanteric hip fractures. Illustrative cases are provided and guidelines for avoiding these surgical pitfalls suggested

Fifteen two-part surgical neck fractures of the humerus in 14 patients were treated with a modified-tension band wiring technique. In this technique, one wire is placed through the greater tuberosity and supraspinatus tendon, and the other wire is placed through the lesser tuberosity and subscapularis tendon. Each wire is connected to the shaft in a similar figure-of-eight technique. This places the wires approximately 90 degrees apart from each other, with neither wire crossing over the biceps tendon. Four (26.7%) fractures had early loss of fixation, and one patient was lost to follow-up. Follow-up evaluation in the remaining 10 fractures (nine patients) averaged 33.4 months (range 26 to 53 months). Clinically, there were three (30%) excellent results, five (50%) satisfactory results, one (10%) unsatisfactory result, and one (10%) failure with the rating scale described by Neer. Based upon these results we cannot recommend the tension band wiring technique used. We consider the high incidence of loss of fixation (26.7%) reported in this series to be unacceptable.

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