A standardized method for the assessment of shoulder function

The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the shoulder. The form has a patient self-evaluation section and a physician assessment section. The patient self-evaluation section of the form contains visual analog scales for pain and instability and an activities of daily living questionnaire. The activities of daily living questionnaire is marked on a four-point ordinal scale that can be converted to a cumulative activities of daily living index. The patient can complete the self-evaluation portion of the questionnaire in the absence of a physician. The physician assessment section includes an area to collect demographic information and assesses range of motion, specific physical signs, strength, and stability. A shoulder score can be derived from the visual analogue scale score for pain (50%) and the cumulative activities of daily living score (50%). It is hoped that adoption of this instrument to measure shoulder function will facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing of this and other available instruments to measure shoulder function and outcome.

Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients

BACKGROUND

Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands.

OBJECTIVES

The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers.

RESEARCH DESIGN

Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records.

SUBJECTS

The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997.

MEASURES

Quality of care, postoperative pain and functioning, and length of acute hospital stay.

RESULTS

Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions.

CONCLUSIONS

Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.

Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip

We prospectively studied 367 patients who had a fracture of the hip, to determine the effect of an operative delay on postoperative complications and on the one-year mortality rate. All of the patients were at least sixty-five years old, cognitively intact, living at home, and able to walk before the fracture. An operative delay was defined as an interval of three calendar days or more between the time of admission to the hospital and the operation. The operation was performed within two calendar days after admission in 267 (73 per cent) of the patients. When the factors of the patient's age and sex and the number of pre-existing medical conditions were controlled, it was found that an operative delay beyond this period approximately doubled the risk of the patient dying before the end of the first postoperative year. When the patient's age and sex and the severity of pre-existing medical conditions were controlled, there was also an increase in mortality associated with an operative delay, although this was not significant. With the numbers studied, an operative delay beyond two calendar days did not have a significant effect on the prevalence of complications during hospitalization. We concluded that an operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients who have a fracture of the hip and who are cognitively intact, able to walk, and living at home before the fracture. Optimally, such patients should have the operation within two calendar days after admission to the hospital.

Quantifying success after total shoulder arthroplasty: the minimal clinically important difference

BACKGROUND

Knowledge of the minimal clinically important difference (MCID) for different shoulder outcome metrics and range of motion after total shoulder arthroplasty (TSA) can be useful to establish a minimum threshold of improvement that defines successful treatment. This study quantifies how MCID varies with different prosthesis types, patient age, gender, and length of follow-up after TSA.

METHODS

A total of 466 anatomic TSA (aTSA) and reverse TSA (rTSA) with 2-year minimum follow-up were performed by 13 shoulder surgeons. The MCID for the American Shoulder and Elbow Surgeons, Constant, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale for pain scores, as well as active abduction, forward flexion, and external rotation, were calculated for different prosthesis types and patient cohorts using an anchor-based method.

RESULTS

The anchor-based MCID results were American Shoulder and Elbow Surgeons = 13.6 ± 2.3, Constant score = 5.7 ± 1.9, University of California Los Angeles Shoulder Rating Scale = 8.7 ± 0.6, Simple Shoulder Test score = 1.5 ± 0.3, Shoulder Pain and Disability Index score = 20.6 ± 2.6, global shoulder function = 1.4 ± 0.3, pain visual analog scale  = 1.6 ± 0.3, active abduction = 7° ± 4°, active forward flexion = 12° ± 4°, and active external rotation = 3° ± 2°. Female gender and rTSA were associated with lower MCID values compared with male gender and aTSA patients.

CONCLUSION

The minimum improvement necessary for patients to achieve a result they believe is clinically meaningful after aTSA and rTSA is nominal and was achieved by at least 80% of the patients. Future endeavors should investigate the influence of different anchor questions on the MCID calculation.

A potential role for interleukin-7 in T-cell homeostasis

Interleukin (IL)-7 is known to up-regulate thymopoietic pathways of T-cell regeneration. Recent work also has shown it to potently enhance thymic-independent peripheral expansion and to restore immunocompetence in athymic T-cell-depleted hosts. We hypothesized that endogenous IL-7 could contribute to the restoration of T-cell homeostasis following T-cell depletion. To analyze this, we evaluated circulating IL-7 levels and lymphocyte subsets in multiple clinical cohorts with T-cell depletion of varying etiologies. In pediatric (n = 41) and adult (n = 51) human immunodeficiency virus-infected CD4-depleted patients, there were strong inverse correlations between IL-7 levels and CD4 counts (r = -0.77, P <.0001, and r = -0.68, P <.0001). Declines in IL-7 were temporally correlated with recovery of CD4 counts. Similar patterns were observed in CD4-depleted patients receiving cancer chemotherapy (r = -0.65, P =.009). Therefore, in 2 disparate clinical scenarios involving CD4 depletion, IL-7 levels dynamically respond to changes in CD4 T-cell number, making this cytokine uniquely suited as a candidate regulator of T-cell homeostasis. Furthermore, in patients with idiopathic CD4 lymphopenia, a much weaker relationship between IL-7 levels and peripheral blood CD4 counts was observed, suggesting that an impaired IL-7 response to CD4 depletion may contribute to the impaired lymphocyte homeostasis observed in this population. In light of the known effects of IL-7 on T-cell regeneration, we postulate that increased availability of IL-7 could play a critical role in restoring T-cell homeostasis following T-cell depletion.

Differential injury responses in oral mucosal and cutaneous wounds

Oral mucosa heals faster than does skin, yet few studies have compared the repair at oral mucosal and cutaneous sites. To determine whether the privileged healing of oral injuries involves a differential inflammatory phase, we compared the inflammatory cell infiltrate and cytokine production in wounds of equivalent size in oral mucosa and skin. Significantly lower levels of macrophage, neutrophil, and T-cell infiltration were observed in oral vs. dermal wounds. RT-PCR analysis of inflammatory cytokine production demonstrated that oral wounds contained significantly less IL-6 and KC than did skin wounds. Similarly, the level of the pro-fibrotic cytokine TGF-b1 was lower in mucosal than in skin wounds. No significant differences between skin and mucosal wounds were observed for the expression of the anti-inflammatory cytokine IL-10 and the TGF-beta1 modulators, fibromodulin and LTBP-1. These findings demonstrate that diminished inflammation is a key feature of the privileged repair of oral mucosa.

The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility

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.

Effects of enzyme replacement therapy on the cardiomyopathy of Anderson-Fabry disease: a randomised, double-blind, placebo-controlled clinical trial of agalsidase alfa

BACKGROUND

Anderson-Fabry disease is an X-linked glycosphingolipid storage disorder caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. This leads to a progressive accumulation of globotriaosylceramide (Gb(3)) in the lysosomes of cells throughout the body that ultimately results in premature death from renal, cardiac or cerebrovascular complications. Until recently, there was no effective therapy available for this disease. The present study was designed to assess the safety and efficacy of enzyme replacement therapy with agalsidase alfa on the cardiac manifestations of Anderson-Fabry disease.

METHOD

The effects of therapy with agalsidase alfa on cardiac structure and function were assessed in a randomised, double-blind, placebo-controlled study of 15 adult male patients with Anderson-Fabry disease. The following parameters were measured at baseline and 6 months: left ventricular mass, QRS duration and levels of Gb(3) in cardiac tissue, urine sediment and plasma. After 6 months of the randomised trial patients were enrolled in a 2-year open-label extension study.

RESULTS

Left ventricular mass, as measured by MRI, was significantly reduced following 6 months of treatment with agalsidase alfa compared with placebo (p = 0.041). A mean 20% reduction in myocardial Gb(3) content as assessed by serial transvenous endomyocardial biopsies was demonstrated over the 6 months of enzyme replacement compared to a mean 10% increase in patients receiving placebo (p = 0.42)

CONCLUSION

Enzyme replacement therapy with agalsidase alfa resulted in regression of the hypertrophic cardiomyopathy associated with Anderson-Fabry disease.

Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care

BACKGROUND

In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare."

METHODS

A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis.

RESULTS

Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline.

CONCLUSION

Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings.

LEVEL OF EVIDENCE

IV economic and decision analyses-developing an economic or decision model.

Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder

PURPOSE

To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder.

MATERIALS AND METHODS

From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography.

RESULTS

SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography.

CONCLUSION

MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.

The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases

STUDY DESIGN

A prospective multicenter study on 100 consecutive surgical procedures.

OBJECTIVES

A prospective multicenter study was performed to evaluate the early perioperative complications in 100 endoscopic spinal procedures--78 video-assisted thoracic surgical procedures and 22 laparoscopic lumbar instrumentation and fusion procedures.

SUMMARY OF BACKGROUND DATA

Endoscopic procedures have been widely applied in general surgery for appendectomy, cholecystectomy, liver resection, Nissen fundoplication, colon resection, and hernia repairs. Video-assisted thoracic surgery is widely used for pleural biopsy, lung resection, and sympathectomy. This is the first large series to date investigating the safety and potential complications using endoscopic surgery for anterior decompression or fusion of the thoracolumbar spine.

METHODS

Video-assisted thoracic surgical procedures included multilevel anterior thoracic releases for deformity, 27 patients; anterior thoracic discectomies with spinal canal decompression, 41 patients; pyogenic vertebral osteomyelitis decompression, 2 patients; and vertebral corpectomy for neurologic decompression, 8 patients. Mean operative time was 2 hours, 34 minutes (range, 45 minutes to 6 hours), and mean length of stay was 4.97 days (range, 2-21 days). Anterior laparoscopic interbody stabilization and fusion at L4-5 or L5-S1 was performed in 22 patients. The mean operative time was 4 hours, 17 minutes (range, 2 hours, 40 minutes to 9 hours), and the mean length of stay was 5.6 days (range, 1-23 days).

RESULTS

The most common video-assisted thoracic surgical complications were transient intercostal neuralgia (six patients) and atelectasis (five patients). The most common laparoscopic complication was bone graft donor site infection (two patients). There were two endoscopic cases that were converted to open procedures, one for extensive pleural adhesions and one for a common iliac vein laceration.

CONCLUSIONS

The endoscopic spinal approaches proved to be safe operative procedures in 100 consecutive cases. There were no permanent iatrogenic neurologic injuries and no deep spinal infections.

A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons

The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the elbow. This form was developed by the Research Committee of the American Shoulder and Elbow Surgeons and subsequently adopted by the membership. The patient self-evaluation section contains visual analog scales for pain and a series of questions relating to function of the extremity. The responses to the questions are scored on a 4-point ordinal scale. The physician assessment section has 4 parts: motion, stability, strength, and physical findings. It is hoped that adoption of this method of data collection will stimulate multicenter studies and improve communication between professionals who assess and treat patients with elbow disorders.

Hip fractures in the elderly: predictors of one year mortality

OBJECTIVE

To determine the one year mortality following hip fracture in an ambulatory, community dwelling, cognitively intact elderly population and to examine the role of specific type, number, and severity of associated medical comorbidities.

DESIGN

Prospective, consecutive.

METHODS

Six hundred twelve elderly who sustained a non-pathologic hip fracture were followed.

RESULTS

Twenty-four patients (4%) died during hospitalization; seventy-eight (12.7%) died within one year of fracture. The factors that were predictive of mortality, based on multivariate analysis, were patient age > 85 years, preinjury dependency in basic activities of daily living, a history of malignancy other than skin cancer, American Society of Anesthesiologists rating of operative risk 3 or 4, and the development of one or more in-hospital postoperative complications; all factors other than the development of an in-hospital complication were independent of treatment.

CONCLUSION

These results indicate that efforts at reducing one year mortality after hip fracture should be directed at the prevention of postoperative complications.

The role of intraoperative frozen sections in revision total joint arthroplasty

We performed a retrospective analysis of thirty-three consecutive total hip and knee (twenty-three hip and ten knee) revision arthroplasties during which intraoperative frozen sections were analyzed. Data for the study were collected by means of a review of the charts, radiographic analysis, and evaluation of both frozen and permanent histological sections. The frozen sections, of periprosthetic tissue at the bone-cement interface or the pseudocapsule, were considered positive for active infection if there were more than five polymorphonuclear leukocytes per high-power field in at least five distinct microscopic fields. All patients were available for follow-up, at an average of thirty-six months (range, seventeen to seventy-nine months) after the initial revision operation. The frozen sections from ten patients were positive for infection, and those from twenty-three patients were negative. Comparison of the results of the analyses of the frozen sections (both positive and negative) with those of the analyses of the permanent histological sections of similar tissue showed a correlation of 100 per cent (sensitivity, 1.00; specificity, 1.00; and accuracy, 1.00). Nine patients had positive intraoperative cultures, and all of them had positive frozen sections (sensitivity, 1.00). Of the twenty-four patients who had negative intraoperative cultures, twenty-three had negative frozen sections (specificity, 0.96). Of the nine patients who had positive intraoperative cultures, only two were found to have infection on intraoperative gram-staining. The surgeon's operative assessment regarding the presence of infection, compared with the final pathological diagnosis, demonstrated a sensitivity of 0.70, a specificity of 0.87, and an accuracy of 0.82. All ten patients who had positive frozen sections were managed with excision arthroplasty; six of them subsequently had reimplantation, and the excision was the definitive procedure in the remaining four. One patient who had had a delayed reimplantation had a secondary skin slough and eventually was managed with an arthrodesis of the knee. In the group that had negative frozen sections, eighteen patients had a primary exchange revision arthroplasty and five had a delayed reimplantation. At the time of follow-up, one patient who had had a delayed reimplantation had radiographic loosening of the femoral component and was asymptomatic. One patient who had had a primary exchange arthroplasty was managed with a second revision because of aseptic loosening. There was no clinical recurrence of infection in any patient. The data indicate that analysis of frozen sections of periprosthetic tissue is a reliable predictor of the presence of active infection during revision joint arthroplasty. We recommend its use to differentiate aseptic from septic loosening.

Relationship of echocardiographic indices to pulmonary capillary wedge pressures in healthy volunteers

OBJECTIVES

We sought to determine the relationship between different echocardiographic indices and pulmonary capillary wedge pressures (PCWP) in normal volunteers.

BACKGROUND

Indices based on tissue Doppler (TDE) and color M-mode (CMM) echocardiography have been proposed to reflect left (LV) ventricular filling pressures. These include the ratio of early diastolic transmitral velocity (E) to early myocardial velocity measured by TDE (E') and the ratio of E to the wave propagation velocity (Vp) measured from CMM images. These indices, however, have not been validated in normal individuals.

METHODS

We studied seven volunteers during two phases of preload altering maneuvers, baseline, with two stages of lower body negative pressure, and repeat baseline with two stages of volume loading. The PCWP obtained from right heart catheterization was compared with diastolic indices using pulsed Doppler, TDE and CMM echocardiography.

RESULTS

The PCWP ranged from 2.2 to 23.5 mm Hg. During preload alterations, significant changes in E and septal E' (both p < 0.05) but not lateral E' or Vp were observed. Furthermore, E, septal E' and E/Vp correlated with PCWP (all r > 0.80) but not combined E and TDE indices (both r < 0.15). Within individuals, a similar linear relationship was observed among E/Vp, E and septal E' (average r > 0.80).

CONCLUSIONS

In subjects without heart disease, E, septal E' and E/Vp correlate with PCWP. Because the influence of ventricular relaxation is minimized, the ratio E/Vp may be the best overall index of LV filling pressures.

Mortality risk after hip fracture

OBJECTIVE

To determine the mortality risk following hip fracture and identify factors predictive of increased mortality.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Tertiary care orthopaedic hospital.

BACKGROUND

Approximately 250,000 hip fractures occur annually in the United States. The greatest mortality risk following hip fracture has been demonstrated to be within the first 6 months of fracture, and some studies report that the risk approaches expected mortality after 6 months. However, more recent studies have demonstrated that an increased risk of mortality may persist for several years postfracture. The purpose of this study was to assess the excess mortality associated with hip fracture at up to 2 years postinjury.

METHODS

All patients with a hip fracture who were admitted to our institution over a 10-year period were evaluated. Criteria for inclusion included: Caucasian, age 65 or older, previously ambulatory, and home dwelling. Patients were followed prospectively to determine the mortality risk associated with hip fracture over a 2-year follow-up period. Mortality was compared to a standardized population and standardized mortality ratios were calculated.

RESULTS

Eight hundred thirty-six patients met the inclusion criteria and were included. The mortality risk was highest within the first 3 months following fracture, with standardized mortality ratios approaching that of the control population by two years. Patients age 65-84 had higher mortality risk when compared with patients age > or =85. American Society of Anesthesiologists classification was predictive of increased mortality risk in younger patients, with these patients having triple the mortality risk when compared to the reference population at 2-year follow-up. More elderly patients had minimal excess mortality associated with hip fracture at 1- and 2-year follow-up, regardless of ASA classification.

CONCLUSION

The data demonstrate that hip fracture is not associated with significant excess mortality amongst patients older than age 85. Amongst younger patients, however, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.

Gender differences in patients with hip fracture: a greater risk of morbidity and mortality in men

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.

The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty

A prospective study was performed to determine the reliability of analysis of intraoperative frozen sections for the identification of infection during 175 consecutive revision total joint arthroplasties (142 hip and thirty-three knee). The mean interval between the primary and the revision arthroplasty was 7.3 years (range, three months to twenty-three years). To reduce selections bias, tissue was obtained for frozen sections during all revisions in patients who did not have active drainage from the wound or a sinus tract. Of the 175 patients, twenty-three had at least five polymorphonuclear leukocytes per high-power field on analysis of the frozen sections and were considered to have an infection. Of these twenty-three, five had five to nine polymorphonuclear leukocytes per high-power field and eighteen had at least ten polymorphonuclear leukocytes per high-power field. The frozen sections for the remaining 152 patients were considered negative. On the basis of cultures of specimens obtained at the time of the revision operation, nineteen of the 175 patients were considered to have an infection. Of the 152 patients who had negative frozen sections, three were considered to have an infection on the basis of the results of the final cultures. Of the twenty-three patients who had positive frozen sections, sixteen were considered to have an infection on the basis of the results of the final cultures; all sixteen had frozen sections that had demonstrated at least ten polymorphonuclear leukocytes per high-power field. The sensitivity and specificity of the frozen sections were similar regardless of whether an index of five or ten polymorphonuclear leukocytes per high-power field was used. Analysis of the frozen sections had a sensitivity of 84 per cent for both indices, whereas the specificity was 96 per cent when the index was five polymorphonuclear leukocytes and 99 per cent when it was ten polymorphonuclear leukocytes. However, the positive predictive value of the frozen sections increased significantly (p < 0.05), from 70 to 89 per cent, when the index increased from five to ten polymorphonuclear leukocytes per high-power field. The negative predictive value of the frozen sections was 98 per cent for both indices. The current study suggests that it is valuable to obtain tissue for intraoperative frozen sections during revision hip and knee arthroplasty. At least ten polymorphonuclear leukocytes per high-power field was predictive of infection, while five to nine polymorphonuclear leukocytes per high-power field was not necessarily consistent with infection. Less than five polymorphonuclear leukocytes per high-power field reliably indicated the absence of infection.

Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures

Twenty-six hemiarthroplasties were performed for acute three- and four-part proximal humerus fractures between March 1986 and December 1991. Postoperative pain, active range of motion, and function were evaluated in 22 patients at a mean follow-up period of 30 months (range 12 to 66 months) with the American Shoulder and Elbow Surgeons evaluation form. Seventy-three percent of patients reported only slight or no pain. Active forward elevation averaged 107 degrees, external rotation averaged 31 degrees, and the average internal rotation was to the second lumbar vertebra. Strength and stability were rarely problematic. Seventy-three percent of patients reported difficulty with at least three of 15 functional tasks tested. Lifting, carrying a weight, and using the hand at or above shoulder level were the most common limitations. This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

The effects of nutritional status on outcome after hip fracture

OBJECTIVE

To determine the effect of nutrition on patient outcome after hip fracture.

STUDY DESIGN

Retrospective review of prospectively collected data.

METHODS

Four hundred ninety hip fracture patients had albumin and total lymphocyte count levels determined at the time of admission and constituted the study population. These variables were examined as predictors for outcomes, including: in-hospital mortality, postoperative complications, hospital length of stay, hospital discharge status, one-year mortality rate, ambulatory ability, and independence in basic and instrumental activities of daily living twelve months after surgery.

RESULTS

Eighty-seven patients (18 percent) were found to be malnourished on hospital admission based on a preoperative albumin level of < 3.5 grams/deciliter, and 280 patients (57 percent) based on a total lymphocyte count of < 1,500 cells/milliliter. An albumin level of < 3.5 grams/deciliter was predictive for increased length of stay (p = 0.03) and for in-hospital mortality (p = 0.03). A total lymphocyte count < 1,500 cells/milliliter was predictive for one-year mortality (p < 0.01). Patients with abnormal albumin and total lymphocyte count were 2.9 times more likely to have a length of stay greater than two weeks (p = 0.03), 3.9 times more likely to die within one year after surgery (p = 0.02), and 4.6 times less likely to recover their prefracture level of independence in basic activities of daily living (p < 0.01). Neither parameter was predictive for patients developing a postoperative complication, hospital discharge status (home versus nursing home), recovery of prefracture ambulatory ability, or independence in instrumental activities of daily living at twelve-month follow-up.

CONCLUSION

Patients at risk for poor outcomes after hip fracture can be identified using relatively inexpensive laboratory tests such as albumin and total lymphocyte count.

Functional outcome after minimally displaced fractures of the proximal part of the humerus

One hundred and four patients who had a minimally displaced fracture of the proximal part of the humerus (a so-called one-part fracture) were managed with a standardized therapy regimen and followed for more than one year. The clinical outcome was assessed on the basis of pain, function, and the range of motion of the shoulder. The duration of follow-up averaged forty-one months (range, twelve to 117 months). All fractures united without additional displacement. Eighty patients (77 per cent) had a good or excellent result, fourteen (13 per cent) had a fair result, and ten (10 per cent) had a poor result. Ninety four patients (90 per cent) had either no or mild pain in the shoulder, eight (8 per cent) had moderate pain, and two (2 per cent) had severe pain. Functional recovery averaged 94 per cent; forty-eight patients (46 per cent) had 100 per cent functional recovery. At the time of the most recent follow-up, forward elevation of the injured shoulder averaged 89 per cent; external rotation, 87 per cent; and internal rotation, 88 per cent that of the uninjured shoulder. The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.

The relationship between admission hemoglobin level and outcome after hip fracture

OBJECTIVE

To determine the effect of admission hemoglobin level on patient outcome after hip fracture.

STUDY DESIGN

Prospective, consecutive.

PATIENTS

From July 1991 to June 1997, 395 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed up.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, in-hospital mortality rate, hospital length of stay, hospital discharge status, place of residence at one year, and mortality and recovery of ambulatory ability and activities of daily living status at three, six, and twelve months.

RESULTS

Women with admission hemoglobin levels below 12.0 grams per deciliter and men with admission hemoglobin levels below 13.0 grams per deciliter were classified as anemic. One hundred eighty patients (45.6 percent) were considered anemic on admission. Patients who were anemic were more likely to have an American Society of Anesthesiologists rating of III or IV and have sustained an intertrochanteric fracture. Hospital length of stay and mortality rate at six and twelve months were significantly higher for patients who were anemic on admission. There were no differences in the incidence of postoperative complications, hospital discharge status, place of residence at one year, in-hospital mortality rate, and three-month mortality rate between patients who were and were not anemic on admission. In addition, there were no differences in the recovery of ambulatory ability and of basic and instrumental activities of daily living status at three, six, and twelve months between the two patient groups.

CONCLUSIONS

Patients at risk for poor outcomes after hip fracture can be identified by assessing hemoglobin levels at hospital admission.

Efficacy of injections of corticosteroids for subacromial impingement syndrome

A prospective, randomized, controlled, double-blind clinical study was performed to determine the short-term efficacy of subacromial injection of corticosteroids for the treatment of subacromial impingement syndrome. Forty patients were randomized to receive either six milliliters of 1 per cent lidocaine without epinephrine (the control group) or two milliliters containing forty milligrams of triamcinolone acetonide per milliliter with four milliliters of 1 per cent lidocaine without epinephrine (the corticosteroid group). The patients were re-examined serially until completion of the study. Nineteen patients, whose mean age was fifty-six years (range, thirty-two to eighty years), were randomized to the corticosteroid group, and twenty-one patients, whose mean age was fifty-seven years (range, thirty-two to eighty-one years), were randomized to the control group. The mean duration of symptoms before the injection was eight months for both groups. Eighteen patients in the corticosteroid group and nineteen patients in the control group had moderate or severe pain before the injection. At the most recent follow-up evaluation, at a mean of thirty-three weeks for the corticosteroid group and twenty-eight weeks for the control group, three patients in the corticosteroid group had moderate or severe pain, compared with fifteen patients in the control group. The mean active range of forward elevation and external rotation improved by 24 and 11 degrees, respectively, for the corticosteroid group and by 10 and 5 degrees, respectively, for the control group. We concluded that subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome. The use of such injections can substantially decrease pain and increase the range of motion of the shoulder.

Management of bone loss associated with recurrent anterior glenohumeral instability

The diagnosis and treatment of osseous deficiencies associated with anterior shoulder instability have been a challenge to physicians for centuries. Whereas historical goals centered on the stable reduction and prevention of recurrent dislocation, current standards of success are predicated on the restoration of motion and strength and the return to functional activities, including competitive athletics. Reestablishment of anterior shoulder stability thus requires the recognition of osseous defects of the humeral head and glenoid, as well as a thorough understanding of the available treatment options in the context of a disciplined treatment algorithm. Although many surgical procedures have been described for the management of osseous deficiencies in association with anterior shoulder instability, in the authors' experience, such procedures are seldom necessary. The purpose of this summary is to review treatment options as well as indications and techniques to address these bony deficiencies.