Faculty Bibliography

In a prospective, consecutive study conducted at a university teaching hospital, we evaluated the effects of Parkinson's disease (PD) on hip fracture outcomes. We followed 920 community-dwelling patients, aged 65 or older, who sustained a hip fracture that was operatively treated between July 1, 1987, and June 30, 1998. Presence or absence of PD had no bearing on type of surgery performed. Examined outcomes were postoperative complication rates; in-hospital mortality; length of hospital stay; discharge status (to home or to a skilled nursing facility); and mortality rate, place of residence, recovery of prefracture ambulatory ability, and return to prefracture activities of daily living (ADLs) 1 year after surgery Thirty-one patients (3.4%) had a history of PD before hip fracture. Patients with PD were more likely to be male, to live with another person, to have less ambulatory ability, and to be dependent in ADLs before hip fracture. Compared with patients without PD, they were hospitalized significantly longer and were more likely to be discharged to a skilled nursing facility. In addition, they declined more in level of independence in basic ADLs but not as much in instrumental ADLs at 1-year follow-up. Rates of postoperative complications, recovery of ambulatory ability within 1 year, and mortality within 1 year did not differ. These findings may guide orthopedic surgeons in counseling patients with PD and a hip fracture

We describe temporal and regional variation in hip fracture rates for people aged 65 or older in New York state (NYS) from 1985 to 1996. Our descriptive study was of all hip fracture cases admitted to NYS hospitals during that period. Case data were obtained from the Statewide Planning and Research Cooperative System (SPARCS) of the NYS Department of Health. US Census Bureau population estimates were obtained for each year from 1985 to 1996 to compute the annual hip fracture rate for each NYS county. These rates were adjusted for differences in age, gender, and race and were compared using logistic regression. Approximately 14,000 hip fractures occurred annually from 1985 to 1996. The annual rate (number of hip fractures per 1000 population) decreased from 6.4 in 1985 to 5.3 in 1996. White women aged 85 or older had the highest rate (26/1000); nonwhite men aged 65 to 69 had the lowest rate (<1/1000). Statewide annual rates decreased slightly over time, but this change was not reflected in all age, gender, and race subgroups. There was important, consistent variation in county rates after adjustment for age, gender, and race. Other researchers have identified geographic variation in national rates, but the postulated environmental and weather-related factors (eg, water fluoridation use; rainfall and sunshine amounts) have explained only a small proportion of this variation. Identification of risk factors that can better explain regional rate variation may lead to development of intervention strategies that could significantly reduce the risk for hip fracture among people 65 or older

OBJECTIVES: To compare the biomechanical stability of internal fixation of extra-articular, dorsally unstable distal radius fractures fixed by 1 of 2 methods, either a standard dorsal nonlocked T-plate or a volar locked fixed-angle plate. DESIGN: Biomechanical cadaveric study. SETTING: Biomechanical testing laboratory. INTERVENTION: In 6 matched pairs of fresh-frozen cadaveric specimens, a simulated unstable extra-articular distal radius fracture was created. The fractures were stabilized with either a dorsal 3.5-mm stainless steel T-plate or a titanium locked volar fixed-angle plate. Specimens were axially loaded at 5 points (centrally, volarly, dorsally, radially, and ulnarly) and then cyclically loaded for 5000 cycles with an 80 N central load. Postcyclical loading, specimens were once again axially loaded at the 5 points. MAIN OUTCOME MEASURES: Initial fixation stiffness and stiffness after midaxial cyclical loading was compared at the 5 points. RESULTS: With the volar locked fixed-angle plate, fixation was significantly stiffer than with the dorsal nonlocked T-plate for ulnar and volar loading in single-cycle testing. After cyclic loading, the locked volar fixed-angle plate maintained more of its initial stiffness than the dorsal nonlocked T-plate. The dorsal 3.5-mm stainless steel T-plate's stiffness when dorsally loaded significantly decreased after cyclical loading. CONCLUSIONS: The volar locked fixed-angle plate maintained a greater percentage of its initial stiffness after cyclic loading compared to the dorsal nonlocked plate. Also, the volar locked plate was stiffer than the dorsal nonlocked plate for all loading configurations tested except when subjected to a dorsally applied eccentric load

Hip fractures have been among the most studied injury patterns in adults. The number of hip fractures is increasing exponentially, and their treatment costs place great economic strain on society. Recently developed hip fracture treatments, emphasizing cost containment, deformity prevention, and evidence-based medicine, are attempts to optimize patient outcomes. In this article, we outline some of these developments with respect to femoral neck and intertrochanteric fractures

OBJECTIVE: To determine gender-specific differences in prefracture status and postoperative outcome in elderly hip fracture patients who were ambulatory, community-dwelling, and cognitively intact prior to fracture. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Urban orthopedic referral hospital. PATIENTS: A total of 983 consecutive patients (206 males and 777 females) who sustained a nonpathologic hip fracture were followed for a minimum of 12 months. INTERVENTION: Operative treatment of a proximal femur fracture. MAIN OUTCOME MEASUREMENTS: Postoperative medical complications, place of discharge, 1-year mortality, and postoperative recovery of ambulation, basic activities of daily living, and instrumental activities of daily living. RESULTS: Men were more likely to be married or living with someone else, and they were more dependent in instrumental activities of daily living than women prior to hip fracture. Furthermore, men were sicker as evidenced by a higher American Society of Anesthesiologists rating of preoperative risk. Postoperatively, men were more likely to sustain a medical complication and had a higher mortality at 1 year compared to women. There were no statistically significant gender differences in patient age, fracture type, prefracture level of help, ambulation, or dependence in basic activities of daily living, place of discharge, and postoperative recovery of ambulation as well as basic and instrumental activities of daily living. CONCLUSIONS: Male gender was a risk factor for sustaining a postoperative complication as well as a higher mortality at 1 year post hip fracture

A prospective study was conducted to determine the efficacy of using recombinant BMP-7 (rhOP-1) as an adjuvant in the treatment of diaphyseal humeral nonunions. Twenty-three consecutive patients with atrophic humeral diaphyseal nonunions were treated at seven separate institutions. All nonunions were fixed with either a compression plate or an intramedullary nail in conjunction with various bone grafting techniques. Recombinant OP-1 was delivered to the fracture site in a Type I collagen carrier at the time of fixation. All fractures went on to eventual union. There were no serious complications and no adverse reactions to the rhOP-I implant. Our study suggests that rhOP-1 may be a safe and effective adjuvant for the treatment of humeral diaphyseal nonunions

The purpose of this study was to determine the effect of the last hemoglobin level before patient discharge on outcome after hip fracture. We retrospectively reviewed data prospectively collected from July 1987 to December 1997 on 844 community-dwelling patients 65 or older who had sustained an operatively treated femoral neck or intertrochanteric fracture. Women with postoperative hemoglobin levels below 12.0 g/dL and men with levels below 13.0 g/dL were classified as having anemia. The main outcome measures were mortality, return to ambulatory ability, and return to activities of daily living at 3, 6, and 12 months. Hemoglobin data were available for 714 patients (85%). At time of last hemoglobin level measurement before discharge, 643 (90.1%) of the 714 patients were classified as having anemia. Patients who had sustained a femoral neck fracture that was treated with internal fixation were less likely to have anemia than were patients who had sustained a femoral neck fracture that was treated with hemiarthroplasty and patients who had sustained an intertrochanteric fracture (P < .001). Patients with anemia at the last discharge were not at increased risk for adverse outcomes at 3, 6, or 12 months compared with patients who did not have anemia

BACKGROUND: The purpose of this study was to confirm the prevalence of medial ankle widening among patients with an isolated fibular fracture and to determine the functional outcome of nonoperative treatment despite a diagnosis of a supination-external rotation stage-IV injury based on stress radiography. METHODS: One hundred and one patients with evidence of an isolated fibular fracture and an intact mortise seen on a standard ankle trauma radiograph series were evaluated with stress radiographs. Clinical signs were recorded at the time of presentation. A positive stress test was defined as > or =4 mm of widening of the medial clear space. Patients with a negative stress test were treated nonoperatively, those with a positive stress test and clinical signs of medial injury were treated surgically, and those with a positive stress test and no signs of medial injury were treated according to the preference of the surgeon and patient. The patients were followed prospectively with radiographs and ankle outcome scores. RESULTS: Sixty-six (65%) of the 101 patients had a positive stress radiograph. Thirty-six of them had signs of medial injury, and thirty had no medial injury. With regard to predicting a positive stress radiograph, medial tenderness had a sensitivity of 56% and a specificity of 80%, swelling had a sensitivity of 55% and a specificity of 71%, and ecchymosis had a sensitivity of 26% and a specificity of 91%. Of the subset of patients without signs of medial injury, twenty were treated nonoperatively (group I) and ten were treated operatively (group II). Two of the twenty patients in group I had evidence of persistent widening of the medial clear space at the time of the latest follow-up (mean, 7.4 months); only one of those patients was symptomatic. The average American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 points in group I and 93 points in group II. CONCLUSIONS: We found a high rate of positive stress radiographs for patients who presented with an isolated fibular fracture and an intact ankle mortise on the initial radiographs. Medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. All of the patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result

BACKGROUND: The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction. METHODS: Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance. RESULTS: Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction. CONCLUSION: Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients