Faculty Bibliography

Fourteen patients with Stage II or III impingement syndrome (average age 58 years) were studied. Nine patients had full-thickness rotator cuff tears documented by arthrograms. Patients initially underwent a thorough shoulder examination followed by baseline isokinetic strength testing. Abduction/adduction testing was performed utilizing a Biodex dynamometer. Maximum concentric contractions were performed, and values for peak torque (PT), total work (W), and power (P) were obtained. All patients received a subacromial injection of 5 cc 1% lidocaine plus 5 cc 0.5% bupivacaine (Marcaine). After 5 minutes the testing sequence was repeated. Clinically, patients demonstrated marked improvement following injection. Eighty-six percent reported complete pain relief; the remaining two patients reported only mild discomfort at the extremes of motion. Improvement in functional activity of the affected shoulder was noted by all subjects. On manual muscle testing, 13 of 14 patients (93%) demonstrated increased abduction strength; 11 of 14 (79%) had improvement in external rotation. Mean increases in active forward elevation and external rotation were 36 degrees and 11 degrees, respectively (P < .01). Postinjection isokinetic changes in PT, W, and P for abduction/adduction were dramatic. For abduction, all patients showed significant increases in P (mean 82%), W (mean 90%), and PT (mean 48%) (all P < .05). No significant differences in range of motion testing or strength parameters were noted based on the presence or absence of a rotator cuff tear. For adduction, all patients showed significant increases in P (mean 208%), W (mean 183%), and PT (mean 41%) (all P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

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

A biomechanical cadaver study was performed to compare the stability and ultimate strength of 3 standard fixation techniques used for treatment of basicervical hip fractures. Twenty one pairs of mildly osteoporotic femurs were selected, based on a computed tomography bone density reading of 40-50 Hounsfeld units and a Singh index of III. After initial mechanical characterization of intact femurs, basicervical femoral neck fractures were created, reduced, and then instrumented with random assignment to 1 of 3 methods of fixation: (1) 3 parallel 6.5-mm cannulated cancellous screws; (2) a 135 degrees sliding hip screw with a 4 hole side plate; and (3) a 135 degrees sliding hip screw with a 4 hole side plate and a 6.5-mm cannulated cancellous screw placed proximal and parallel to the sliding screw. Nine pairs were tested to failure in axial loading, 6 pairs in lateral bending, and 6 pairs in torsion. The group instrumented with the multiple cancellous screws had a significantly (p < 0.01) lower ultimate axial load to failure than either sliding hip screw group. However, the multiple screws demonstrated significantly (p < 0.01) less fracture displacement. There were no statistically significant differences in lateral bending or torsional testing behavior between the 3 fixation methods. Use of the sliding hip screw is recommended rather than use of multiple cancellous screws for treatment of basicervical femoral neck fractures. Although a superiorly located cancellous screw may provide rotational control during sliding hip screw insertion, it provides no incremental fixation after the sliding hip screw is placed

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.

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

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

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