Marvin Gilbert

Functional Outcomes and Mortality Vary among Different Types of Hip Fractures: A Function of Patient Characteristics

A review of prospectively collected data was done to compare functional outcomes and mortality among patients with different hip fracture types. Five hundred thirty-seven elderly patients who sustained a hip fracture were followed up prospectively. Orthopaedists blinded to treatment and outcome radiographically classified the fractures as either: (1) nondisplaced or impacted femoral neck; (2) displaced femoral neck; (3) stable intertrochanteric; or (4) unstable intertrochanteric fracture. Functional independence measure scores were calculated for preinjury function and at 2- and 6- month followups. Comorbidities, operative details, postoperative complications, and deaths were recorded. Six-month mortality was lowest for patients with nondisplaced femoral neck fractures (5.7%) and highest for patients with displaced femoral neck fractures (15.8%), but multivariate analysis only identified preinjury function as an independent predictor of mortality. All preinjury and followup functional independence measure scores were greatest for patients with nondisplaced femoral neck fractures and least for patients with unstable intertrochanteric fractures. However, multivariate analysis identified only patient age and preinjury functional independence measure scores as independent predictors of functional outcome. These data show differences in mortality and functional outcomes among fracture types that can be attributed to differences in functional status before injury.

Hip Fracture in the Older Patient: Reasons for Delay in Hospitalization and Timing of Surgical Repair

OBJECTIVES: To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture.

CHARACTERIZING THE HEMOPHILIC PSEUDOTUMOR

The term “orthopedie,” first used by Nicholas Andry in 1741, was derived from the Greek-ortho (straight) and puidiu (child)-literally, “to straighten the child.” Hemophilia is one of the most challenging tests the present-day orthopedist is faced with. Musculoskeletal hemorrhage is the most common manifestation of these coagulation disorders. Hemorrhage may occur into three distinct anatomic sites: (1 ) into the joint, with the formation of arthropathy; (2) into the soft tissues, with consequent contracture and/or neuropathy; and (3) into or in proximity to bone, with the formation of a pseudotumor. The latter is the least common lesion, but its formation is most serious as it represents a potential threat to both life and limb. Because of their relative rarity, few physicians have great experience in treating these lesions. Little is known about the basic pathology. This presentation, which is based upon a review of the literature and personal experience with those few cases followed at the Hemophilia Clinic of Mount Sinai Hospital, New York, will attempt to correlate the known pathology, characterize the lesion, and propose a rational plan of therapy. Starker 1 has been generally credited with describing the first pseudotumor, in 1918. Since then over 60 cases have been described. Fernandez de Valderrama and Matthews characterized the pseudotumor as “a progressive cystic swelling involving muscle, produced by recurrent hemorrhage and accompanied by radiographic evidence of bone involvement.” Gunning estimated an incidence of 1 % of severe hemophiliacs. Pseudotumors have been described in the long bones (especially those of the lower extremity), the pelvis, and the small bones of the hands and feet. The femur is the most common site, accounting for slightly over one-third of all reported cases. The pelvis, the next most common site, accounts for slightly under one-third of the cases. The tibia and the bones of the feet account for most of the rest, a few being reported in the hand or at the wrist. The average age at which the patient with a pseudotumor presented for medical care is quite interesting. Most every pseudotumor in the femur and pelvis presented in a mature patient. In contrast, those noted in the small bones of the hand and foot all occurred in the young patient with open epiphyseal growth plates. Even more interesting was the fact that many of the latter patients had or developed multiple pseudotumors, which has not been reported in the older patient with the more proximal lesion. The proximal lesion, as exemplified in the femur, was preceded by a history of trauma and developed over many years. At the hand and foot, trauma was less frequent and the patient sought medical advice within one year. These findings suggested to me that there may be two distinct clinical patterns, and further analysis seemed to confirm this. The large femoral pseudotumor usually presented as a painless expanding mass. A history of trauma may be elicited with slow resolution of a hematoma

Outcomes of elderly patients with nondisplaced femoral neck fractures.

Seventy patients with nondisplaced femoral neck fractures treated by cannulated screw fixation were followed up prospectively for 6 months. Preinjury Functional Independence Measure scores and comorbidities were recorded as were operative time, type of anesthesia, estimated blood loss, transfusions, and postoperative complications. Functional Independence Measure scores were reassessed at 3 and 6 months. The mean age of the patients was 78 years. The 6-month mortality was 5.7%. The mean overall Functional Independence Measure scores at 3 and 6 months were 86% and 89% of the initial score respectively. Locomotion Functional Independence Measure scores at 3 and 6 months were 73% and 89% of the initial score, respectively. Multiple regression analysis found patient age and initial overall Functional Independence Measure score to be independent predictors of overall, locomotion, and transfer Functional Independence Measure scores at 3 months. At 6 months, only initial Functional Independence Measure score predicted ultimate Functional Independence Measure scores. This suggests that patient age may affect the speed of recovery but not the ultimate functional result. Of comorbidities, only chronic obstructive pulmonary disease significantly affected functional recovery at 3 months, but not at 6 months. Operative time, estimated blood loss, type of anesthesia, and patient gender did not affect functional outcomes. Patients who sustain a nondisplaced femoral neck fracture experience predictable and lasting loss of function. Low initial functional status predicts a poorer outcome. Age and pulmonary comorbidity affect speed of recovery.

Acromioclavicular dislocations: treatment by transfer of the conjoined tendon and distal end of the coracoid process to the clavicle.

A retrospective study of 23 acute and 6 chronic acromioclavicular dislocations treated by surgical transfer of the distal 1/2 inch of the coracoid process with the attached conjoined tendon of the coracobrachialis and short head of the biceps to the clavicle revealed 14 excellent, 14 good and one fair result. Results were determined according to symptoms, range of motion at the shoulder and elbow, strength, anatomic reduction, and return to previous activities. Although most patients with this injury are treated conservatively, this procedure is reserved for the athlete or manual laborer below age 45 years, especially with involvement of the dominant-extremity. The 29 cases were evaluated 20--108 months following surgery. Thirteen additional cases with less than 18 month follow-up have also been good or excellent. Weakness and pain have not been as pronounced following this procedure in vigorous individuals as have been noted after conservative treatment. Few postoperative complications developed, and early return to competitive athletics was possible.

Therapeutic options in the management of hemophilic synovitis.

There is a complex relationship between recurrent bleeding, synovitis, and the development of arthritis in the patient with hemophilia. There are many options available for the treatment of recurrent bleeding and hemophilic synovitis, indicating that none works very well. Conservative treatment, including replacement of the missing clotting factor for 3 to 6 months, intermittent steroids, immobilization, and physical therapy should be tried before synovectomy is indicated. Synovectomy can be achieved through an open procedure, arthroscopically, or by injection of a radioactive material into the joint. Radioactive synovectomy is indicated in patients with inhibitors to the clotting factor, patients with advanced human immunodeficiency virus and advanced hepatitis, and in those patients with multiple joint involvement. Arthroscopic synovectomy is the procedure the authors recommend for the knee and ankle joints, although open synovectomy offers an excellent alternative. The greatest risk to these procedures is a decreased range of motion, and this is most problematic in the young child who cannot cooperate with a program of physical therapy.

Long term evaluation of septic arthritis in hemophilic patients.

Before 1983, septic arthritis was rare in patients with hemophilia. With the advent of human immunodeficiency virus infection in the hemophilia population, many centers noted an increasing incidence of patients with septic arthritis. Fifteen septic joints in 10 patients with severe hemophilia were documented. Eight patients were human immunodeficiency virus positive, 1 was human immunodeficiency virus negative, and 1 was not tested. The diagnosis was delayed in 5 patients because the symptoms are similar to an acute hemarthrosis. An elevated temperature was common. The white blood cell count was elevated in only ⅓ of the infections, being modified by human immunodeficiency virus infection. Associated risk factors included infected angioaccess catheters (2), pneumonia (2), and generalized sepsis (1). All but 1 joint responded to appropriate antibiotics and either repeated aspiration or arthrotomy. However, 6 patients died of acquired immunodeficiency syndrome from 2 to 109 months after infection. Three patients are alive 29, 86, and 96 months, respectively, after infection.

Unipolar or bipolar prosthesis for the displaced intracapsular hip fracture? An unanswered question.

Modular bipolar prostheses were developed to address the problems of loosening, cartilage wear, and protrusio which were seen with single unit endoprostheses. Modular unipolar prostheses address many of these problems and are significantly less expensive than the bipolar prosthesis. Recent data suggest that use of the modular unipolar prosthesis is indicated in elderly patients with low demands.

Introduction of intracapsular hip fractures: anatomy and pathologic features.

The morbidity, mortality, and financial burden related to intracapsular hip fractures in elderly patients in the United States will continue to increase as the population ages. An appreciation of the anatomy and pathologic features of intracapsular hip fractures is necessary for successful treatment.

A retrospective radiographic review of hemophilic shoulder arthropathy.

Bleeding into large joints is the most common orthopaedic manifestation of hemophilia. Involvement of the shoulder rarely is reported, lending to its relative neglect in the orthopaedic literature. Through retrospective chart and radiographic reviews, the incidence and progression of radiographic and clinical changes that occur in the shoulder of patients with hemophilia is described. We retrospectively reviewed 822 patient charts and found 93 patients with symptomatic shoulders. Seventy-nine of these 93 patients were rated according to Pettersson’s scoring method. The clinical charts were reviewed for the presence of shoulder symptoms and dysfunction. A spectrum of radiographic changes was seen beginning with mild subchondral irregularity and greater tuberosity cyst formation progressing to joint space narrowing, osteophyte formation, marginal erosion, and deformity. Of the 54 patients for whom an adequate shoulder history was available, the severity of symptoms correlated with the Pettersson score. The current study is the largest to date examining the type and progression of radiographic changes caused by hemophilic shoulder arthropathy. We observed a consistent pattern of radiographic changes, the severity of which correlated directly with shoulder symptoms.