Search

Background: Fracture liaison services (FLS) have proven to be effective in treating osteoporosis associated with fragility fractures. For patients with fragility fractures of the hip, FLS programs are expected to be cost-effective because of the high risk of re-fracture and the high cost of fracture treatment. In this study we evaluate the essential factors in determining whether the FLS saves or loses more than it costs. Methods: A prospective-randomized study was done in patients with hip fragility fractures using a hospital-based FLS program in parallel with a cost analysis. Data was generated from a cohort of patients using actual data for FLS effectiveness, individual costs of hip fracture treatment, and medication costs based on an accepted treatment algorithm. Results: There were 200 patients randomized and 180 analyzed for costs. Results showed that the cost-benefit of the FLS was dependent on the medication used for osteoporosis. Specifically, using the medication algorithm in this study, the loss per patient enrolled in the FLS was $671 for a 2-year period. If intravenous zoledronic acid had been used, then the loss would have been $221. If only oral bisphosphonates had been used, then the FLS would have saved $109 per patient for a 2-year period. Conclusions: The analysis done here shows that medication cost is the critical component in cost-effectiveness of a FLS program. Additional work needs to be done refining the medication algorithm considering medication costs but individualized to patient needs based on fracture risk. Trial Registration: NCT02239523

We evaluated the frequency of absence of the palmaris longus tendon in the heterogeneous Israeli population. Nine hundred and fifty wrists were evaluated using a modified Mishra/Schaeffer technique (thumb/little-finger opposition with resisted wrist flexion), which was validated by ultrasound scanning. The geographical and ethnic origin of volunteers was documented. When physical examination was equivocal, any vague, superficial structure was subsequently identified as the median nerve by ultrasound. Physical examination reliably identified palmaris longus only when a structure was clinically obvious (visually or by palpation). There was bilateral absence of the palmaris longus in 21% and unilateral absence in 15% of participants. Frequency of bilateral absence varied between 4.5% and 30%, depending on geographical origin ( p = 0.0007). The incidence of palmaris longus tendon varied significantly by geographical, but not by ethnic origin. Level of evidence: II

Background For most patients, tennis elbow (TE) resolves within 6 months of onset. For those with persistent and painful TE, nonsurgical treatment options are limited. Thousands of studies have tried to find effective treatments for TE but have usually failed. In this study, we tested the hypothesis that injections with hyaluronic acid (HA) would be effective at reducing pain from chronic TE. Methods Patients with a minimum of six months of pain from TE and with a pain level of 50 or greater (out of 100) were included in the study. They were randomized equally into one of two treatment groups: injection with HA or injection with saline control. Follow-up was conducted at 3, 6 and 12 months from the initial injection. Both the patient and the examiner at the follow-up visits were blinded to the treatment arm. The primary outcome measure was the visual analog scale (VAS pain) score at one year. Additional outcome measures included the shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and Patient Rated Tennis Elbow Evaluation (PRTEE) scores. Results Eighteen patients were randomized into the HA injection treatment arm, and 17 (94%) completed the study. The average age was 51.9 years, and 10 of the subjects were male. Patients had an average of 28.1 months of pain before entering the study. The VAS score in the HA group decreased from a baseline of 76.4–14.3 at 12 months. All 17 patients in the HA group showed VAS score reductions above the minimal clinically important difference (MCID) of at least 18. The PRTEE score improved from 67 to 28.1. The QuickDASH score improved from 53.7 to 22.5. Follow-up in the saline group was less than 50% and was therefore not used as a comparator. Conclusions HA injections yielded significant success in pain relief by three months. Patients continued to improve for the 12-month duration of the study. This study indicates that patients with chronic lateral epicondylitis may benefit from receiving injections of hyaluronic acid rather than having to undergo surgery.

CASE We present the rare event of median nerve bony entrapment after a supracondylar distal humerus fracture in a child. The median nerve was both clinically and electrically still, partially intact at 2 years after the injury. The nerve was surgically extracted from the bone. Follow-up evaluation a year later showed motor and sensory improvement. We found only 2 similar reports in the literature and one similar postmortem example. CONCLUSION We hope that this case brings awareness of an unusual complication after a commonly encountered injury.

Introduction Patients with clinical suspicion of hip fracture, but negative radiographs are suspected of having an occult hip fracture (OHF). Different diagnostic modalities are available for investigating OHF and various protocols have been suggested. MRI has the highest sensitivity and specificity, however availability is limited in many institutes. CT is readily accessible in the large majority of hospitals throughout the world but has lower sensitivity and may miss some fractures. In this article we investigate a protocol that balances these issues providing a practical and cost-effective solution. Methods During a four-year period between 2012 and 2016 a strict diagnostic protocol was followed at our Medical Center for patients suspected of OHF. This MRI selective protocol consisted of CT initially being performed and only when negative for fracture, followed by an MRI. Retrospective analysis of all patients who followed the protocol was performed. The patients were divided into two groups: those diagnosed by CT alone and those diagnosed by MRI after having a negative CT scan. Diagnostic performance, time to diagnosis and the cost of this protocol were evaluated. Results 103 patients were treated under the protocol. In 50 patients (49%) hip fracture was diagnosed by CT alone. In the remaining 53 patients (51%) no definitive diagnosis was reached by CT and MRI was subsequently performed. 12 of these 53 patients (23%) were diagnosed with hip fracture necessitating surgery. In the CT only group mean time from admission to diagnosis was 3 hours, in the CT + MRI group this rose to 40 hours. Cost analysis showed that this protocol was more cost-effective than performing MRI in all patients, saving an estimated 66,805 Euro during the study period. Conclusion The clinical challenge of diagnosing OHF can be minimised by implementing a diagnostic protocol. The protocol should take into consideration the diagnostic sensitivity, availability and cost of different imaging modalities. An MRI selective strategy with initial CT scanning is recommended, as it reduces time to diagnosis and lowers overall costs.

Aims: Patients who present with fragility fractures are consistently under-evaluated and under-treated for underlying osteoporosis. This point-of-care represents a lost opportunity to prevent future fractures. This 2-arm study evaluated the success by an orthopaedic department in osteoporosis evaluation and initiating treatment. Methods: Patients over the age of 50 years with a fragility fracture of the hip were candidates for inclusion. Exclusion criteria included end-of-life care and moderate or severe dementia. Patients were prospectively randomized into 1 of 2 groups. The Letter group received a letter at the time of discharge encouraging their primary care physician to start medication for osteoporosis (Letter group). The intervention group had 4 interventions including printed information, a DEXA scan, a specific treatment recommendation, and monthly phone calls for 4 months (Intervention group). The primary outcome measure was whether the patient was on recommended treatment at 4 months from the fracture. Results: There were 200 patients in the study, 100 in the Letter, and 100 in the Intervention group. Sixteen patients were removed from the study since they either died (9) within 4 months of their fracture, were transferred for end-of-life care (7), and 4 dropped out. This left 180 patients for analysis. The Letter group had only 6 patients (6.2%) on recommended treatment compared with the Intervention group with 64 patients (77.1%). This was statistically significant (P

Purpose To compare the outcomes of nonsurgical and surgical treatment of children with wrist ganglia. Methods We performed a retrospective review of children with wrist ganglia treated at 2 separate institutions. In one, a clinic setting, children were treated with observation. In the other, a hospital referral center, children had surgical excision. Information obtained included persistent or recurrent cyst, and Quick–Disabilities of the Arm, Shoulder, and Hand measure. Patients aged 17 years or less at the time of cyst appearance with at least 1 year of follow-up were included. Results We successfully contacted 90 patients: 50 in the nonsurgical and 40 in the surgical group. Average follow-up was 4.6 years. The persistence rate in the nonsurgical group was 52%. The recurrence rate in the surgical group was 15%. In the nonsurgical group, if a ganglion resolved, it did so within 18 months in 94% of patients. Dorsal ganglions persisted more often than volar ones (63% vs 33%). Older children had a higher rate of persistence than did younger children (58% vs 31%). For children aged 10 or less, surgery was associated with a recurrence rate of 17%, compared with 31% persistence in the nonsurgical group. For children aged 11 and more, surgery was associated with a recurrence rate of 15%, compared with 58% persistence in the nonsurgical group. There was no significant difference between Quick–Disabilities of the Arm, Shoulder, and Hand scores in any group. Conclusions In a child with a wrist ganglion, if the cyst ultimately resolved, it usually did so within 18 months. Dorsal ganglion cysts and ganglion cysts in older children have a higher chance of persisting. In children treated with surgical excision, we found a 15% recurrence rate. Type of study/level of evidence Therapeutic IV.

To examine our hypothesis that the accuracy of visual estimation, while measuring the angles of forearm, wrist and elbow, may vary between the different angles, and that this may depend on the experience of the observer.A slide show comprising of clinical photos and radiographs of different elbow, forearm and wrist angles was presented to 164 attending orthopedic surgeons, orthopedic residents and medical students who made a visual estimation of the different joints' angles.Forearm pronation was found to be estimated most accurately (mean 6.1°) while radiographs of wrist flexion (mean 12°) and photos of wrist extension (mean 16°) were estimated the least accurately. Specialists estimated angles more accurately than residents and both were more accurate than students, regardless of the estimated joint.The accuracy of visual estimation of a joint's angle depends on the specific joint viewed. Experience in the practice of orthopedic surgery (and not only upper extremity surgery) will improve the accuracy of estimation in general. Regarding the elbow, forearm and wrist, the results of our study suggest that a goniometer should be used whenever an accuracy of up to 10° is important, and for measuring wrist flexion and extension.

Purpose Scaphoid fractures are classified according to their 2-dimensional radiographic appearance, and transverse waist fractures are considered the most common. Our hypothesis was that most scaphoid fractures are not perpendicular to the longitudinal axis of the scaphoid (ie, not transverse). Methods Computerized 3-dimensional analyses were performed on 124 computed tomography scans of acute scaphoid fractures. Thirty of the fractures were displaced and virtually reduced. The angle between the scaphoid's first principal axis (longitudinal axis) and the fracture plane was analyzed for location and displacement. The distal radius articular surface was used to depict the volar–dorsal vector of the wrist. Results There were 86 fractures of the waist, 13 of the distal third, and 25 of the proximal third. The average angle between the scaphoid longitudinal axis and the fracture plane was 53° for all fractures and 56° for waist fractures, both differing significantly from a 90°, transverse fracture. The majority of fracture planes were found to have a volar distal to dorsal proximal (horizontal oblique) inclination relative to the volar–dorsal vector. Conclusions Most waist fractures were horizontal oblique and not transverse. According to these findings, fixation of all fractures along the longitudinal axis of the scaphoid may not be the optimal mode of fixation for most. A different approach may be needed in accordance with the fracture plane. Type of study/level of evidence Diagnostic II.

BACKGROUND Epidermolysis bullosa (EB) is a group of inherited, mechanobullous disorders caused by mutations in various structural proteins in the skin. The manifestation of these disorders in the hand is of digital contractures and pseudosyndactyly or "cocoon hands," causing significant functional impairment.Our preferred surgical treatment of these patients involves separation of the digits from the palm by releasing the finger flexion contractures and separating them, primarily the adducted thumb. However, recurrence is common. Our hypothesis was that functional improvement is gained irrespective of recurrence of contractures. METHODS We retrospectively evaluated 4 patients, 2 male and 2 female, whose average age was 11 years, treated surgically by the separation of all their digits and by coverage with skin grafts. The follow-up period was between 1 and 3½ years. RESULTS Partial recurrence of the deformity was observed in all patients. Recurrence was more pronounced in the nondominant hand, especially between the digits and of flexion contractures, but did not preclude the use of precision or oppositional pinch at final follow-up. The patient with the longest follow-up has been referred for revision surgery to gain further release of contractures.Significant rehabilitation goals were achieved in all 4 patients after surgery. After 6 months, both of the younger patients were measured for finger dexterity, which showed lower scores than the norm, although this was felt to be dependent on which daily manual activities they were more familiar with. These tests could not have been performed before surgery. CONCLUSIONS All patients and families felt the effort was worthy. Separating the thumb and straightening the digits was found to be significant, yet the indication for separating all the digits is debatable. The need for revision surgery, to maintain the digit function, is clear. LEVEL OF EVIDENCE Level 4, case series.