Roger Cornwall

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.

Nerve injury in traumatic dislocation of the hip.

Neurologic injury often accompanies traumatic dislocation and fracture-dislocation of the hip. A review of the literature reveals an incidence of approximately 10% in adults and 5% in children. The sciatic nerve, usually the peroneal branch, is most often injured, and this complication can be seen after all types of posterior fracture-dislocations and simple posterior dislocations. The sciatic nerve can be acutely lacerated, stretched, or compressed, or later encased in heterotopic ossification. Neurologic examination at the time of injury often is difficult but is extremely important. Once a nerve injury is discovered, prompt closed reduction must be attempted to relieve distortion of the nerve from a dislocated femoral head or displaced acetabular fracture. Considerable controversy surrounds the recommendations for additional treatment of nerve injury once the hip has been reduced. At least partial recovery of nerve function occurs in 60% to 70% of patients, with no clear correlation with injury or treatment type. Rehabilitation of patients with sciatic nerve injury must begin as early as possible and should focus on the prevention of an equinus foot deformity. Magnetic resonance neurography may become useful in the future for initial evaluation of patients with this injury.

Impaired growth of denervated muscle contributes to contracture formation following neonatal brachial plexus injury.

BACKGROUND The etiology of shoulder and elbow contractures following neonatal brachial plexus injury is incompletely understood. With use of a mouse model, the current study tests the novel hypothesis that reduced growth of denervated muscle contributes to contractures following neonatal brachial plexus injury. METHODS Unilateral brachial plexus injuries were created in neonatal mice by supraclavicular C5-C6 nerve root excision. Shoulder and elbow range of motion was measured four weeks after injury. Fibrosis, cross-sectional area, and functional length of the biceps, brachialis, and subscapularis muscles were measured over four weeks following injury. Muscle satellite cells were cultured from denervated and control biceps muscles to assess myogenic capability. In a comparison group, shoulder motion and subscapularis length were assessed following surgical excision of external rotator muscles. RESULTS Shoulder internal rotation and elbow flexion contractures developed on the involved side within four weeks following brachial plexus injury. Excision of the biceps and brachialis muscles relieved the elbow flexion contractures. The biceps muscles were histologically fibrotic, whereas fatty infiltration predominated in the brachialis and rotator cuff muscles. The biceps and brachialis muscles displayed reduced cross-sectional and longitudinal growth compared with the contralateral muscles. The upper subscapularis muscle similarly displayed reduced longitudinal growth, with the subscapularis shortening correlating with internal rotation contracture. However, excision of the external rotators without brachial plexus injury caused no contractures or subscapularis shortening. Myogenically capable satellite cells were present in denervated biceps muscles despite impaired muscle growth in vivo. CONCLUSIONS Injury of the upper trunk of the brachial plexus leads to impaired growth of the biceps and brachialis muscles, which are responsible for elbow flexion contractures, and impaired growth of the subscapularis muscle, which correlates with internal rotation contracture of the shoulder. Shoulder muscle imbalance alone causes neither subscapularis shortening nor internal rotation contracture. Impaired muscle growth cannot be explained solely by absence of functioning satellite cells.

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.

Initial treatment of traumatic hip dislocations in the adult.

The initial treatment of traumatic hip dislocations is critical to successful treatment of this injury. It generally is agreed that prompt reduction with the patient under anesthesia or sedation is required. Delay in reduction of posterior hip dislocations is associated with avascular necrosis of the hip. Occasionally the hip dislocation will be irreducible. Various methods to reduce hip dislocations have been described in the literature. The superiority of one particular technique has not been shown and the choice of reduction maneuver must be tailored to the condition of the patient. Traumatic hip dislocations often are associated with multiple injuries that may limit the options available for initial treatment of the hip dislocation. Adherence to general principles of skeletal reduction will increase the ease of reduction and decrease the risk of iatrogenic injury during reduction. Additional clinical and radiographic evaluation of the hip that was reduced often is necessary to determine whether subsequent open treatment is required.

Early Functional Recovery of Elbow Flexion and Supination Following Median and/or Ulnar Nerve Fascicle Transfer in Upper Neonatal Brachial Plexus Palsy

BACKGROUND Nerve transfers using ulnar and/or median nerve fascicles to restore elbow flexion have been widely used following traumatic brachial plexus injury, but their utility following neonatal brachial plexus palsy remains unclear. The present multicenter study tested the hypothesis that these transfers can restore elbow flexion and supination in infants with neonatal brachial plexus palsy. METHODS We retrospectively reviewed the cases of thirty-one patients at three institutions who had undergone ulnar and/or median nerve fascicle transfer to the biceps and/or brachialis branches of the musculocutaneous nerve after neonatal brachial plexus palsy. The primary outcome measures were postoperative elbow flexion and supination as measured with the Active Movement Scale (AMS). Patients were followed for at least eighteen months postoperatively unless they obtained full elbow flexion or supination (AMS = 7) prior to eighteen months of follow-up. RESULTS Twenty-seven (87%) of the thirty-one patients obtained functional elbow flexion (AMS ≥ 6), and twenty-four (77%) obtained full recovery of elbow flexion against gravity (AMS = 7). Of the twenty-four patients for whom recovery of supination was recorded, five (21%) obtained functional recovery. Combined ulnar and median nerve fascicle transfers were performed in five patients and resulted in full recovery of elbow flexion against gravity and supination of AMS ≥ 5 for all five. Single-fascicle transfer was performed in twenty-six patients and resulted in functional flexion in 85% (twenty-two of twenty-six) and functional supination in 15% (three of twenty). Patients with nerve root avulsion were treated at a younger age (p < 0.01), had poorer preoperative elbow flexion (p < 0.01), and recovered greater supination (p < 0.01) compared with patients with dissociative recovery. Younger patients (p < 0.01) and patients with C5-C6 avulsion (p < 0.02) recovered the greatest supination. One patient sustained a transient anterior interosseous nerve palsy after median nerve fascicle transfer. CONCLUSIONS Ulnar and/or median nerve fascicle transfers were able to effectively restore functional elbow flexion in patients with nerve root avulsion, dissociative recovery, or late presentation following neonatal brachial plexus palsy. Recovery of supination was less, with greater success noted in younger patients with nerve root avulsion.

The effects of denervation, reinnervation, and muscle imbalance on functional muscle length and elbow flexion contracture following neonatal brachial plexus injury.

The pathophysiology of paradoxical elbow flexion contractures following neonatal brachial plexus injury (NBPI) is incompletely understood. The current study tests the hypothesis that this contracture occurs by denervation‐induced impairment of elbow flexor muscle growth. Unilateral forelimb paralysis was created in mice in four neonatal (5‐day‐old) BPI groups (C5‐6 excision, C5‐6 neurotomy, C5‐6 neurotomy/repair, and C5‐T1 global excision), one non‐neonatal BPI group (28‐day‐old C5‐6 excision), and two neonatal muscle imbalance groups (triceps tenotomy ± C5‐6 excision). Four weeks post‐operatively, motor function, elbow range of motion, and biceps/brachialis functional lengths were assessed. Musculocutaneous nerve (MCN) denervation and reinnervation were assessed immunohistochemically. Elbow flexion motor recovery and elbow flexion contractures varied inversely among the neonatal BPI groups. Contracture severity correlated with biceps/brachialis shortening and MCN denervation (relative axon loss), with no contractures occurring in mice with MCN reinnervation (presence of growth cones). No contractures or biceps/brachialis shortening occurred following non‐neonatal BPI, regardless of denervation or reinnervation. Neonatal triceps tenotomy did not cause contractures or biceps/brachialis shortening, nor did it worsen those following neonatal C5‐6 excision. Denervation‐induced functional shortening of elbow flexor muscles leads to variable elbow flexion contractures depending on the degree, permanence, and timing of denervation, independent of muscle imbalance.

Failed Surgical Management of Partial Thickness Rotator Cuff Tears

Some authors have recommended that rotator cuff tears <50% of tendon thickness be debrided and those involving >50% of the tendon be treated with miniopen repair. We hypothesize that if indications for selecting between simple debridement and tendon repair were appropriate, then both groups should have comparable outcomes. Thirty-nine patients with partial rotator cuff tears met inclusion criteria and were available for retrospective analysis. Twenty-six percent of patients who underwent debridement and 12.5% of patients who had mini-open repair had unsatisfactory results according to Neers criteria.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs.

Background The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum. Methods On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum. Results Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P<0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P<0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P=0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P<0.001). The angle between the neck and shaft lines correlated positively with LCD (P<0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (&kgr;=0.40-0.75). Conclusions The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment. Level of Evidence Diagnostic Level 3.

Implanted neuroprostheses for restoration of hand function in tetraplegic patients.

Abstract Restoration of hand function through functional electrical stimulation allows tetraplegic patients to use existing abilities to control paralyzed muscles. In patients with C5 or C6 spinal cord injuries, implanted upper extremity neuroprostheses use functional electrical stimulation technology to power hand and arm muscles. A variety of devices, often using contralateral shoulder motion, sends signals via a small external controller and transmitting coil to an implanted stimulator. The stimulator powers designated upper extremity muscles via implanted electrodes. The surgical procedure is minimally invasive and easily reversed. Palmar and lateral grasp, among other functions, can be reliably restored, leading to significant improvements in functional capacity. High user satisfaction, low complication rates, and recent advances in technology and control systems contribute to the success of this technology in the treatment of devastating spinal cord injuries.