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The paper focuses on the identification of atypical fractures (AFFs). This paper examines the concordance between objective classification and expert subjective review. We believe the paper adds critical information about how to apply the American Society of Bone and Mineral Research (ASBMR) criteria to diagnose AFFs and is of high interest to the field. Assess American Society of Bone and Mineral Research (ASBMR) criteria for identifying atypical femoral fractures (AFFs). Two orthopedic surgeons independently evaluated radiographs of 372 fractures, applying ASBMR criteria. We assessed ease of applying ASBMR criteria and whether criteria-based assessment matched qualitative expert assessment. There was up to 27% uncertainty about how to classify specific features. 84% of films were classified similarly for the presence of AFF according to ASBMR criteria; agreement increased to 94% after consensus meeting. Of 37 fractures categorized as AFFs based on ASBMR criteria, 23 (62.2%) were considered AFFs according to expert assessment (not relying on criteria). Only one (0.5%) femoral shaft fracture that did not meet ASBMR criteria was considered an AFF per expert assessment. The number of major ASBMR features present (four vs five) and whether there was periosteal or endosteal thickening (“beaking” or “flaring”) played major roles in the discrepancies between ASBMR criteria-based and expert-based determinations. ASBMR AFF criteria were useful for reviewers but several features were difficult to interpret. Expert assessments did not agree with the ASBMR classification in almost one-third of cases, but rarely identified an AFF when a femoral shaft fracture did not meet ASBMR AFF criteria. Experts identified lateral cortical transverse fracture line and associated new-bone formation along with no or minimal comminution as crucial features necessary for the definition of atypical femoral fractures.

Identification of atypical femoral fractures (AFFs) can be challenging. To assist in the radiological assessment, an ASBMR Task Force developed a case definition for AFFs in 2010, revising it in 2013. How the revised definition performs in a community setting compared to the 2010 definition is unknown. We applied the 2013 criteria to 372 femoral fractures that occurred between January 1, 1996, and June 30, 2009, employing two independent expert physician reviewers. We used radiographs that had been categorized in a previous study on the incidence of atypical fractures using 2010 ASMBR criteria (BEAK1). In this follow-up study (BEAK2), the same reviewers reviewed all previously identified femoral shaft fractures (FSFs) (N = 197) and distal femur fractures (N = 131) plus a 15% random sample of intertrochanteric fractures (N = 49). After initial review, agreement between the two reviewers ranged from 63-100% for specific features, and 84% of radiographs received the same overall classification. Fewer fractures met the 2013 compared to 2010 ASMBR case definition of AFFs (37 per 2013 criteria vs. 74 per 2010 criteria). Forty-three radiographs (58%) categorized as AFFs according to 2010 criteria were no longer AFFs when 2013 criteria were applied, and an additional 12 non-atypical FSFs according to 2010 criteria were reclassified as AFFs according to 2013 criteria. The major cause of AFF reclassification was the change in the definition of transverse configuration. The modification of the comminution, non-traumatic, and periosteal/endosteal thickness criteria resulted in the reclassification of non-atypical FSFs to AFFs. Incidence rate of AFFs according to 2013 ASBMR criteria was lower overall during the 13 years of observation than when the 2010 ASBMR criteria were applied, although we saw a slight increase starting in 2000. As in BEAK1, we found that those with AFFs were younger, more often female, and had a higher exposure rate to bisphosphonates than those with non-atypical FSFs. As we continue to unravel the demographics of those who suffer from AFFs, our study adds information about how the change in criteria influences epidemiological work. This article is protected by copyright. All rights reserved

article i nfo Background: Osteoporosis is a major cause of morbidity and mortality. Clinical trials have shown the effectiveness of bisphosphonates, the most commonly prescribed treatments, in reducing fracture risk. The population-based effectiveness of bisphosphonates in clinical practice is uncertain. Methods: This retrospective cohort study used a matched design that compared time to clinical fracture in at- risk community women who initiated a bisphosphonate medication between 7/1/1996 and 6/30/2006 to those who did not. The study was conducted in an HMO in Oregon and Washington. Clinical electronic databases provided data. Eligible members were newly treated women aged ≥55 years with either a BMD T- score of ≤−2.0 or a prior qualifying clinical fracture. They did not have contraindications for bisphosphonate therapy or a diagnosis associated with secondary osteoporosis (n=1829). They were matched to a similar comparison group (n=1829; total N=3658). The primary outcome was the first new incident fracture validated through chart review (closed clinical fracture of any bone except face, skull, finger, or toe or pathological fracture secondary to malignancy) during follow-up. An intention-to-treat analysis used Cox proportional hazards models to estimate the hazard ratio of fracture for treated relative to comparison patients, adjusting for differences in potential confounders. Results: Treated and comparison patients were similar in mean age (72.0 years) and history of fracture (about 45%). The treated group had more women with T-scores of ≤−2.5 (67.3% vs. 54.7%) and a lower mean weight (146.6 lb vs. 151.8 lb). Only about 45% of treated patients had a bisphosphonate medication possession ratio (MPR) of ≥0.80. During follow-up, 198 (10.8%) of patients in the treated group had incident fractures, vs. 179 (9.8%) of patients in the comparison group. After adjustments, patients in the treated group were 0.91 (95% CI 0.74-1.13) as likely to have an incident fracture as the comparison patients (p=0.388). The treatment effect remained non-significant after accounting for MPR. Conclusions: In this analysis of a community cohort of post-menopausal women at risk, the fracture risk of patients who received bisphosphonates did not differ significantly from those who did not. An enhanced understanding of this lack of treatment effect is urgently needed.

This study used in-depth interviews and focus groups to evaluate osteoporosis care after a fracture. Patients (eligible women aged 67 who sustained a clinical fracture(s)), clinicians, and staff stated that an outreach program facilitated osteoporosis care management, but more-tailored education and support and increased participation of orthopedic specialists appear necessary.Osteoporosis treatment reduces fracture risk, but screening and treatment are underutilized, even after a fracture has occurred. This study evaluated key stakeholder perspectives about the care of osteoporosis after a fracture.Participants were from a nonprofit health maintenance organization in the United States: eligible women members aged 67 or older who sustained a clinical fracture(s) (n = 10), quality and other health care managers (n = 20), primary care providers (n = 9), and orthopedic clinicians and staff (n = 28); total n = 67. In-depth interviews and focus groups elicited participant perspectives on an outreach program to patients and clinicians and other facilitators and barriers to care. Interviews and focus group sessions were transcribed and content-analyzed.Patients, clinicians, and staff stated that outreach facilitated osteoporosis care management, but important patient barriers remained. Patient knowledge gaps and fatalism were common. Providers stated that management needed to begin earlier, and longer-term patient support was necessary to address adherence. Orthopedic clinicians and staff expressed lack of confidence in their osteoporosis management but willingness to encourage treatment.Although an outreach program assisted with the management of osteoporosis after a fracture, more-tailored education and support and increased participation of orthopedic specialists appear necessary to maximize osteoporosis management.

The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the SF-36 are used to assess subjective outcome after total hip arthroplasty (THA). Although these indices have been validated, neither the WOMAC nor the SF-36 has been tested for accuracy against objective data in this clinical setting. Thirty osteoarthritic patients undergoing elective primary THA were subjectively evaluated preoperatively and 1 year postoperatively with the WOMAC and the SF-36 and objectively evaluated at the same interval with basic stride analysis and the 6-minute walk test. Correlation analysis of the subjective and objective data (both perioperative improvement and postoperative absolute scores) yielded Pearson coefficients of r = 0.50-0.81. This work demonstrates a sound statistical relationship between walking ability and the functional aspects of the WOMAC and the SF-36, supporting the use of these instruments in assessing the functional outcome after THA.

Ten patients who had undergone primary intraarticular proximal tibial replacement between April 1985 and December 1994, and had a minimum of 2 years of followup, were available for stride analysis. Mean age, time since intraarticular proximal tibial replacement, height, and weight were 23.8 years, 6.5 years, 167 cm, and 63 kg, respectively. A volunteer control group of five male patients who had undergone above knee amputation was obtained from the local community. The mean age, time since above knee amputation, height, and weight were 43.6 years, 24.1 years, 165 cm, and 70 kg, respectively. Stride analysis was performed over the central 6-m portion of a 10-m walkway at a self selected, comfortable pace. Gait velocity, stride length, cadence, and stance time symmetry were measured. Velocity after intraarticular proximal tibial replacement versus above knee amputation was 79.2 +/- 7.6 m per minute versus 71.4 +/- 5.4 m per minute. Cadence after intraarticular proximal tibial replacement versus above knee amputation was 112.4 +/- 10.6 steps per minute versus 110.1 +/- 2.4 steps per minute. There were no significant differences between stride length (1.41 +/- 0.13 m versus 1.43 +/- 0.12 m) and stance time symmetry (0.90 +/- 0.07 versus 0.87 +/- 0.11) for intraarticular proximal tibial replacement versus above knee amputation. The results suggest that endoprosthetic reconstruction resulted in a gait comparable with that after above knee amputation with an external prosthesis.

The case definition, community incidence, and characteristics of atypical femoral shaft fractures (FSFs) are poorly understood. This retrospective study utilized electronic medical records and radiograph review among women ≥50 years of age and men ≥65 years of age from January 1996 to June 2009 at Kaiser Permanente Northwest to describe the incidence rates and characteristics of subgroups of femur fractures. Fractures were categorized based on the American Society for Bone and Mineral Research (ASBMR) as atypical fracture major features (AFMs) (low force, shaft location, transverse or short oblique, noncomminuted) and AFMs with additional minor radiograph features (AFMms) (beaking, cortical thickening, or stress fracture). There were 5034 fractures in the study. The incidence rates of FSFs (without atypical features) and AFMs appeared flat (cumulative incidence: 18.2 per 100,000 person-years, 95% CI = 16.0–20.7; 5.9 per 100,000 person-years, 95% CI = 4.6–7.4; respectively) with 1,271,575 person-years observed. The proportion of AFMs that were AFMms increased over time. Thirty percent of AFMs had any dispensing of a bisphosphonate prior to the fracture, compared to 15.8% of the non-atypical FSFs. Years of oral glucocorticosteroid dispensing appeared highest in AFM and AFMm fractures. Those with AFMs only were older and had a lower frequency of bisphosphonate dispensing compared to those with AFMms. We conclude that rates of FSFs, with and without atypia, were low and stable over 13.5 years. Patients with only AFMs appear to be different from those with AFMms; it may be that only the latter group is atypical. There appear to be multiple associated risk factors for AFMm fractures. © 2012 American Society for Bone and Mineral Research.

A review of the current literature identified two primary causes of avulsion of the lesser trochanter: strenuous flexion of the hip in adolescent athletes with open epiphyses2,5-9,11,15,16 and pathological fracture associated with a metastatic lesion of bone3,14. In both cases, stress concentration at the site of the iliopsoas muscle leads to a tensile failure of either the apophysis or the lesser trochanter. Typically, the force necessary to avulse an otherwise normal apophysis is much greater than that required to produce a pathological fracture, and the latter mechanism is rarely associated with a history of trauma20. We report the cases of four patients who had an avulsion fracture of the lesser trochanter secondary to a primary malignant tumor of bone. To our knowledge, this is the first report in which a pathological fracture of the lesser trochanter was the presenting symptom leading to the diagnosis of such a tumor. In the absence of a traumatic event, an isolated fracture of the lesser trochanter should suggest an underlying pathological process, particularly a primary or metastatic tumor. To avoid inappropriate operative procedures, a pathological diagnosis must be made by means of a biopsy before internal fixation is attempted. CASE 1. A forty-four-year-old man was first seen by us in June 1985 because of a two-week history of pain in the left hip without antecedent trauma. The pain had been insidious in onset and was aggravated by flexion of the hip. The patient had noted an acute worsening of the pain while sailing. At the time of presentation, he also reported pain in the groin and weakness in the left lower extremity. Clinical examination demonstrated weakness and an inability to flex the left hip against resistance secondary …

Total hip arthroplasty, although a very successful clinical treatment, remains an expensive procedure in an era of constrained health care resources. Hospitalization cost, charge, and reimbursement data were compared between all patients who underwent elective, primary, unilateral total hip arthroplasty in 1988 and 1993 at the UCLA Medical Center. Although length of hospitalization decreased by 36%, increases both in unit supply costs and in the intensity of hospital services prevented a statistically significant reduction in total hospitalization cost. Reimbursement declined by 27% after calculating inflation with the Consumer Price Index for Medical Care. Further, the margin by which reimbursement exceeded cost decreased from 66% in 1988 to 8% in 1993. These trends constitute a serious threat to the financial feasibility of total hip arthroplasty.

Published reports describe the clinical efficacy of modified Brostrom anatomic repairs, surgical procedures that involve repair and fortification of the lateral capsuloligamentous complex of the ankle for patients suffering from chronic lateral instability of this joint. A cadaveric serial sectioning study of the anterior talofibular ligament, the calcaneofibular ligament, and the remainder of the anterolateral joint capsule was completed to quantitate the contribution of the superior portion of the anterolateral joint capsule, independent of the other two structures, to the overall mechanical stability of the lateral ankle. Using 20 fresh frozen specimens, talar tilt and anterior drawer stress radiographs were taken before and after sectioning these anatomic structures in an order established by one of two protocols. Sectioning of the superior anterolateral joint capsule caused 17% to 18% of the total displacement in a Grade II sprain simulation and 29% to 33% of the total displacement in a Grade III sprain simulation. This work suggests that disruption of the segment of ankle joint capsule superior to the anterior talofibular ligament creates approximately 30% of the overall laxity encountered in a Grade III inversion sprain, substantiating the principle of restoring the integrity of the entire anterolateral joint capsule when operating on a chronically unstable ankle.