Fragility fracture patients with a history of prior fractures more likely to present with multiple risk factors: findings from a province-wide fracture liaison service.

We examined the demographic characteristics and risk factors of FLS fragility fracture patients who had sustained prior fragility fracture(s) and found that this is an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle. PURPOSE: Our primary objective was to examine whether fragility fracture patients presenting to a provincial fracture liaison service (FLS) having a history of prior fractures, versus those without, differ in demographic characteristics and risk factors for future fracture. A secondary objective was to understand if those who report two or more prior fractures differ from those reporting one prior fracture. METHODS: This cohort study included fragility fracture patients aged 50 + enrolled in the Ontario FLS between July 2017 and September 2019. Patients with versus those without prior fractures were compared on age, sex, index fracture site, biological parents' history of hip fracture, current fracture due to a fall, history of feeling unsteady when walking, history of falls in the past year, smoking, oral steroid use, and comorbid chronic conditions. Pearson's chi-square, Fischer's exact, and analysis of variance tests were used to assess differences. RESULTS: Among 14,454 patients, 16.8% (n = 2428) reported a history of one or more prior fractures after the age of 40. They were significantly more likely to be older, female, with a higher number of comorbidities, with greater incidence of falls, and feel unsteady when walking. Compared to those with one prior fracture, patients with greater than one prior fracture were more likely to report falls in the past year and feel unsteady when walking. CONCLUSION: Findings suggest that FLS fragility fracture patients who had sustained prior fragility fracture are an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service.

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group. PURPOSE: To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up. METHODS: This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening. RESULTS: Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males. CONCLUSIONS: Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

Equal treatment: no evidence of gender inequity in osteoporosis management in a coordinator-based fragility fracture screening program.

We evaluated gender imbalance in osteoporosis management in a provincial coordinator-based fracture prevention program and found no difference by gender in treatment of high-risk fragility fracture patients. This establishes that a systemic approach with interventions for all fragility fracture patients can eliminate the gender inequity that is often observed. INRODUCTION: The purpose of this study was to evaluate an Ontario-based fracture prevention program for its ability to address the well-documented gender imbalance in osteoporosis (OP) management, by incorporating its integrated fracture risk assessments within a needs-based evaluation of equity. METHODS: Fragility fracture patients (≥ 50 years) who were treatment naïve at screening and completed follow-up within 6 months of screening were studied. Patients who underwent bone mineral density (BMD) testing done in the year prior to their current fracture were excluded. All participants had BMD testing conducted through the Ontario OP Strategy Fracture Screening and Prevention program, thus providing us with fracture risk assessment data. Our primary study outcome was treatment initiation at follow-up within 6 months of screening. Gender differences were compared using Fisher's exact test, at p < 0.05. RESULTS: After adjusting for subsequent fracture risk, study participants did not show a statistically significant gender difference in pharmacotherapy initiation at follow-up (p > 0.05). 68.4% of women and 66.2% of men at high risk were treated within 6 months of screening. CONCLUSION: Needs-based analyses show no difference by gender in treatment of high-risk fragility fracture patients. An intensive coordinator-based fracture prevention model adopted in Ontario, Canada was not associated with gender inequity in OP treatment of fragility fracture patients after fracture risk adjustment.

Addition of a fracture risk assessment to a coordinator's role improved treatment rates within 6 months of screening in a fragility fracture screening program.

We evaluated the impact of a more intensive version of an existing post-fracture coordinator-based fracture prevention program and found that the addition of a full-risk assessment improved treatment rates. These findings provide additional support for more intensive programs aimed at reducing the risk of re-fractures. INTRODUCTION: Evidence-based guidelines support coordinator-based programs to improve post-fracture osteoporosis guideline uptake, with more intensive programs including bone mineral density (BMD) testing and/or treatment being associated with better patient outcomes. The purpose of this study was to evaluate the impact of a more intensive version (BMD "fast track") of an existing provincial coordinator-based program. METHODS: We compared two versions of the program that screened treatment naïve fragility fracture patients (>50 years). Cases came from the BMD fast track program that included full fracture risk assessment and communication of relevant guidelines to the primary care provider (PCP). Matched controls were selected from the usual care program matching according to age, sex, fracture type, and date. Two matching techniques were used: traditional (hard) matching (TM) and propensity score matching (PS). The outcomes were treatment initiation with bone sparing medication, BMD testing rate, and the rate of returning to discuss the test results with a PCP. RESULTS: The program improvements led to a significant improvement in treatment initiation within 6 months from 16 % (controls based on PS) or 21 % (controls based on TM) to 32 % (cases). Ninety percent of patients in the BMD fast track program returned to their PCP to discuss bone health in the cases versus 60 % of the controls (for TM and PS). BMD testing occurred in 96 % of cases compared to the 66 (TM) or 65 % (PS) of the matched controls. CONCLUSIONS: Addition of a full-risk assessment to a coordinator-based program significantly improved treatment rates within 6 months of screening.

Factors influencing the pharmacological management of osteoporosis after fragility fracture: results from the Ontario Osteoporosis Strategy's fracture clinic screening program.

UNLABELLED: Potential mediating factors in the pathway to initiation of osteoporosis treatment following a fragility fracture were evaluated. Patients' perceived need for treatment, mediated by their perception of bone density test results, was central to treatment initiation. Interventions focusing on patients' perceptions of need and test results may improve treatment rates. INTRODUCTION: We tested a hypothesized pathway to osteoporosis (OP) pharmacotherapy initiation in fragility fracture patients. We hypothesized that bone mineral density (BMD) testing is strongly associated with treatment initiation and perception of BMD test results would inform patients' perceived need for treatment, which would mediate the effect between BMD testing and treatment initiation. METHODS: A longitudinal cohort study followed patients, ≥50 years of age, screened for fragility fracture in 31 fracture clinics in Ontario, Canada who had no prior diagnosis of or treatment for OP. At screening, OP risk factors, baseline-patient perception of OP risk, OP knowledge, and perceived benefits of medication were reported by patients. Patients were followed up within 6 months of fracture to determine BMD testing and prescription of and adherence to first-line OP pharmacotherapy. Structural equation modeling tested the hypothesized pathway. Significance and magnitude of the coefficients and indicators of overall model fit were used to test our model. RESULTS: The direct path from BMD testing to OP treatment initiation was non-significant. The pathway to treatment initiation was mediated by patients' perception of their need, which was influenced by their self-reported BMD results. Baseline fracture risk factors, knowledge of OP, and perceived benefits of treatment-predicted patient-perceived need for treatment at follow-up and initiation of OP treatment. CONCLUSIONS: Patient perceptions were central factors in the path to initiation of OP pharmacotherapy. Interventions to facilitate accurate patient perceptions of BMD test results and OP risk status could prove helpful in improving OP treatment initiation.

Coordinator-based systems for secondary prevention in fragility fracture patients.

The underlying causes of incident fractures--bone fragility and the tendency to fall--remain under-diagnosed and under-treated. This care gap in secondary prevention must be addressed to minimise both the debilitating consequences of subsequent fractures for patients and the associated economic burden to healthcare systems. Clinical systems aimed at ensuring appropriate management of patients following fracture have been developed around the world. A systematic review of the literature showed that 65% of systems reported include a dedicated coordinator who acts as the link between the orthopaedic team, the osteoporosis and falls services, the patient and the primary care physician. Coordinator-based systems facilitate bone mineral density testing, osteoporosis education and care in patients following a fragility fracture and have been shown to be cost-saving. Other success factors included a fracture registry and a database to monitor the care provided to the fracture patient. Implementation of such a system requires an audit of existing arrangements, creation of a network of healthcare professionals with clearly defined roles and the identification of a 'medical champion' to lead the project. A business case is needed to acquire the necessary funding. Incremental, achievable targets should be identified. Clinical pathways should be supported by evidence-based recommendations from national or regional guidelines. Endorsement of the proposed model within national healthcare policies and advocacy programmes can achieve alignment of the objectives of policy makers, professionals and patients. Successful transformation of care relies upon consensus amongst all participants in the multi-disciplinary team that cares for fragility fracture patients.

Biomechanical validation of finite element models for two silicone metacarpophalangeal joint implants.

Silicone implants are used for prosthetic arthroplasty of metacarpophalangeal (MCP) joints severely damaged by rheumatoid arthritis. Different silicone elastomer MCP implant designs have been developed, including the Swanson and the NeuFlex implants. The goal of this study was to compare the in vitro mechanical behavior of Swanson and NeuFlex MCP joint implants. Three-dimensional (3D) finite element (FE) models of the silicone implants were modeled using the commercial software ANSYS and subjected to angular displacement from 0 deg to 90 deg. FE models were validated using mechanical tests of implants incrementally bent from 0 deg to 90 deg in a joint simulator. Swanson size 2 and 4 implants were compared with NeuFlex size 10 and 30 implants, respectively. Good agreement was observed throughout the range of motion for the flexion bending moment derived from 3D FE models and mechanical tests. From 30 deg to 90 deg, the Swanson 2 demonstrated a greater resistance to deformation than the NeuFlex 10 and required a greater bending moment for joint flexion. For larger implant sizes, the NeuFlex 30 had a steeper moment-displacement curve, but required a lower moment than the Swanson 4, due to implant preflexion. On average, the stress generated at the implant hinge from 30 deg to 90 deg was lower in the NeuFlex than in the Swanson. On average, starting from the neutral position of 30 deg for the preflexed NeuFlex implant, higher moments were required to extend the NeuFlex implants to 0 deg compared with the Swanson implants, which returned spontaneously to resting position. Implant toggling within the medullary canals was less in the NeuFlex than in the Swanson. The differential performance of these implants may be useful in implant selection based on the preoperative condition(s) of the joint and specific patient functional needs.

Patient acceptance of osteoporosis treatment: Application of the stages of change model.

OBJECTIVES: To examine whether a commonly used model of behaviour change, stages of change, is helpful in understanding osteoporosis treatment initiation in a cohort of fragility fracture patients. STUDY DESIGN: This longitudinal cohort study used data from a provincial osteoporosis screening program targeting fragility fracture patients age 50 and over. Logistic regression was used to identify baseline factors associated with patients moving from the first, pre-contemplation stage at baseline to the more advanced stages of action/maintenance at follow-up, when treatment is initiated and maintained. MAIN OUTCOME MEASURE: Patient's stage-of-change readiness to accept osteoporosis treatment. RESULTS: At baseline, 91% of patients were in the pre-contemplation stage. Of these, 74.1% remained at the same stage at follow-up, 2.7% moved to contemplation and preparation while 23.2% moved to action/maintenance. The adjusted analysis showed that those who moved from pre-contemplation to action/maintenance were more likely to have a previous fracture OR 1.5 (1.1-2.0), history of oral steroid use OR 2.1 (1.3-3.5), higher perceived benefits to osteoporosis drug treatment OR 1.2 (1.0-1.3), perception of bones as "thin" OR 2.8 (2.0-4.0) and were less likely to perceive that they were taking too many medications OR 0.6 (0.5-0.9). CONCLUSIONS: With the majority of patients in the pre-contemplation and the action/maintenance stages, our results suggest an existence of a two-stage model. The baseline factors that we identified can be used to predict which patients are less likely to initiate treatment, which in turn, can be used to inform post-fracture interventions and facilitate behaviour change.

Fractal dimension as a measure of altered trabecular bone in experimental inflammatory arthritis.

Our previous studies in experimental inflammatory arthritis (EIA) and in human rheumatoid arthritis demonstrated rapid remodeling with a 5-fold increase in bone resorption and bone formation. Normal condylar trabecular bone is typically anisotropic, with its orientation along lines of stress; rapid remodeling in a pathological state could disturb the usual order of trabeculae. This study assessed change in the structure of trabecular bone of the distal femoral epiphysis after induction of EIA, using a measure of "fractal dimension," which may be considered a quantitative description of the degree of irregularity of complex surfaces. Data was obtained from specimens in which EIA had been induced in the rabbit knee by 10 injections of carrageenan over 49 days. Photographic enlargements of embedded undecalcified cross-sections of the distal femur were digitized, and software written on a Sun workstation was used to define repeatable regions of interest (ROIs) in the images. The ROIs were subjected to fractal analysis by a power law method. The fractal dimension of the trabecular bone pattern within the ROI was estimated by fitting an equation of the form A (epsilon) = lambda epsilon (2-D) to the data. In this equation, A (epsilon) is the area of the "surface" formed by modeling the ROI data as a three-dimensional structure with the grey-level magnitude providing the third dimension, lambda is a scaling constant, epsilon is the size of the measuring "tool" used to measure the area, and D is the fractal dimension. A Mann-Whitney U-test applied to the average of the data from all ROIs showed that the two distributions of fractal dimension were significantly different (p < 0.005). There were only two overlaps between data points for arthritis (with these values higher) and normal groups (n = 11 for each group). Since Howship's lacunae were too small to be resolved in the system utilized, we consider the difference in fractal dimension to be primarily related to trabecular surface orientation, rather than to the increased number of asperities (resorptive foci) occurring due to increased turnover in bone affected by inflammatory arthritis. The results suggest that fractal dimension may be a useful tool for assessing the degree of structural damage to trabeculae in conditions similar to EIA.

Changes in cross-sectional geometry of the distal femoral metaphysis associated with inflammatory arthritis are reduced by a bisphosphonate (zoledronate).

An increased risk of fracture is a feature of rheumatoid arthritis and of animal models of inflammatory arthritis. We examined geometrical changes in the metaphyseal cortex of the distal femur in an animal model of inflammatory arthritis. Additionally, we examined the effect of a bisphosphonate in preventing these changes. Five groups of rabbits were studied: normal controls, those with inflammatory arthritis, and three groups with arthritis treated with bisphosphonate. To determine geometrical properties, image analysis was performed on digitized cross sections of the femoral metaphyseal cortices. The results demonstrated that the posterior cortical wall was significantly less thick in rabbits with arthritis than in normal rabbits and in the rabbits in the three bisphosphonate treatment groups (p < 0.05). Moment of inertia about the lateral-medial axis was reduced in rabbits with arthritis compared with normal rabbits (p < 0.05). Cross-sectional area was not significantly different between groups. The changes suggest a mechanism of weakening of bone in arthritis; when the results are coupled with results of previous porosity studies, severe directional weakness is apparent. Bisphosphonate was effective in preserving bone integrity in inflammatory arthritis.

Zoledronate (CGP 42'446), a bisphosphonate, protects against metaphyseal intracortical defects in experimental inflammatory arthritis.

This study investigated zoledronate (CGP 42'446), a bisphosphonate, as a potential prophylactic and therapeutic agent against intracortical defects in metaphyseal bone in an experimental model of inflammatory arthritis. Inflammatory arthritis was induced in the right tibiofemoral joint of rabbits by the repeated injection of carrageenan. Three groups of animals were treated with the bisphosphonate daily, beginning at different points after the induction of arthritis. Cross sections of the right distal femoral metaphysis were prepared, and intracortical defects were examined by computerized image analysis. The percentage of total bone area with defects (the ratio of void area to total bone area) was greatly increased in the arthritic group compared with that in the normal group (p < 0.001). In all groups treated with the bisphosphonate, there was a significantly lower percentage of total bone area with defects compared with that in the arthritic group (p < 0.001). Treatment was likewise effective in reducing the zonal (anterior and posterior) predilection for the formation of defects observed in arthritis. Although inflammatory arthritis has a substantial effect in producing intracortical defects in metaphyseal bone, a bisphosphonate, zoledronate, was considerably effective in preventing these changes from occurring.

Arthritis not immobilization causes bone loss in the carrageenan injection model of inflammatory arthritis.

One suggested cause of the high turnover osteopenia of experimental inflammatory arthritis is disuse of affected joints. To compare the influence of immobilization or disuse, or both, with that of inflammatory arthritis on bone turnover, rabbits were placed into four groups. In group 1, arthritis was induced in the right knee by seven intra-articular injections of 1% carrageenan, over 49 days; in group 2, a plaster cast was applied to immobilize the right hindlimb in flexion; in group 3, arthritis was induced and the hindlimb was immobilized; and in group 4, nothing was done (control). The fluorescent label calcein was administered in drinking water (0.05%) ad libitum to all groups on days 22-36. On day 49, specimens were prepared for analysis of bone volume and new bone volume at a near site (right femur) and at remote sites (contralateral femur and ipsilateral humerus). The data were analysed by multiple regression and Bonferroni tests. In group 1, new bone volume was three times higher than in group 2 or 4 (p < 0.05 for each comparison); this indicated increased bone remodeling in the right femur. This contrasted with group 2, in which neither index of bone remodeling was changed. The combination of immobilization with arthritis resulted in more intense osseous effects of inflammatory arthritis, with a one-quarter decrease in bone volume (group 3, 30.99 +/- 2.50; group 4, 42.07 +/- 2.38, p < 0.05), as well as a 4-fold increase in new bone volume (p < 0.001) compared with group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Bisphosphonate (pamidronate/APD) prevents arthritis-induced loss of fracture toughness in the rabbit femoral diaphysis.

Patients with rheumatoid and other inflammatory arthritis have an increased risk for fracture. This study was designed to determine the effect of experimental inflammatory arthritis on the material properties (fracture toughness and shear modulus) and structural properties (torque, angular deflection, and absorbed energy) of femoral diaphyseal bone tested in torsion to fracture, as well as the effect on these properties of APD (3-amino-1-hydroxypropylidene-1,1-bisphosphonate), a drug known to block osteoclast activity. Two dose levels were investigated. Experimental inflammatory arthritis was induced by intra-articular injection of carrageenan into the right tibiofemoral joint, given over 7 weeks, in three groups of animals. Simultaneously, daily subcutaneous injections of APD were given to three groups of rabbits. Five groups (12 animals each) were established: normal, arthritis, normal/high dose APD, arthritis/high dose APD, and arthritis/low dose APD. The diaphyses of each excised right femur were loaded to fracture in torsion at an angular deflection rate of 8 degrees/sec. In the arthritis group, the fracture toughness was 39% lower than in the normal group, and the structural properties all were reduced significantly. By contrast, the shear modulus was unaffected by arthritis. In this study, the higher dose level (0.3 mg/kg of body weight) of APD prevented loss of fracture toughness and maintained the structural properties in experimental inflammatory arthritis; the low dose was not effective.

Carrageenan-induced arthritis in the rat.

This study documents a model of carrageenan-induced chronic inflammatory arthritis in the rat, using quantitative histomorphometric assessment. Ten Sprague-Dawley female rats were randomly assigned to one of two groups. Arthritis was induced in the right tibiofemoral joint by 7 intra-articular injections of 0.02 mL of 1% carrageenan in the arthritic group over 24 days. The control (normal) group was injected with 0.02 mL of saline in the right tibiofemoral joint. Sagittal sections of the right knee joint (distal femur and proximal tibia) were assessed by histomorphometry using the LECO 2001 image analysis system. Articular cartilage thickness, epiphyseal plate thickness, subchondral bone plate thickness, trabecular bone volume and thickness of the synovial lining cell layer were measured. Differences between normal and arthritic groups were statistically significant for articular cartilage thickness of the femur, epiphyseal plate thickness of both the femur and tibia, subchondral bone plate thickness of the tibia and the thickness of the synovial lining cell layer. These findings demonstrate that carrageenan-induced arthritic changes are similar to other, established models of arthritis in the rat.

Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis.

BACKGROUND: Osteoarthritis (OA) of the hip is a progressive condition that has no cure and often requires a total hip arthroplasty (THA). The principal methods for THA are the posterior and direct lateral approaches. The posterior approach is considered to be easy to perform, however, increased rates of dislocation have been reported. The direct lateral approach facilitates cup positioning which may decrease rates of hip dislocation and diminishes the risk of injury to the sciatic nerve. However, there is an increased risk of limp. Dislocation of a hip prosthesis is a clinically important complication after THA, in terms of morbidity implications and costs. OBJECTIVES: To determine the risks of prosthesis dislocation, postoperative Trendelenburg gait and sciatic nerve palsy after a posterior approach, compared to a direct lateral approach, for adult patients undergoing THA for primary OA. SEARCH STRATEGY: MEDLINE, EMBASE, CINHAL and Cochrane databases were searched until 2002. No language restrictions were applied. SELECTION CRITERIA: Published trials comparing posterior and direct lateral surgical approaches to THA in participants 18 years and older with a diagnosis of primary hip OA. DATA COLLECTION AND ANALYSIS: Retrieved articles were assessed independently by the two reviewers for their methodological quality. MAIN RESULTS: Four prospective cohort studies involving 241 participants met the inclusion criteria. The primary outcome, dislocation, was reported in two studies. No significant difference between posterior and direct lateral surgical approach was found [1/77 (1.3%) versus 3/72 (4.2%); relative risk (RR) 0.35; 95% confidence intervals (CI) 0.04 to 3.22]. The presence of postoperative Trendelenburg gait was not significantly different between these surgical approaches. The risk of nerve palsy or injury was significantly higher among the direct lateral approaches [1/43 (2%) versus 10/49 (20%); RR 0.16, 95% CI 0.03 to 0.83]. However, there were no significant differences when comparing this risk nerve by nerve for both approaches, in particular for the sciatic nerve. Of the other outcomes considered only the average range of internal rotation in extension of the hip was significantly higher (weighted mean difference 16 degrees, 95% CI 8 to 23) in the posterior approach group (mean 35 degrees, standard deviation 13 degrees ) compared to the direct lateral approach (mean 19 degrees, standard deviation 13 degrees ). REVIEWER'S CONCLUSIONS: The quality and quantity of information extracted from the trials performed to date are insufficient to make any firm conclusion on the optimum choice of surgical approach in adult patients undergoing primary THA for OA.

Successful surgical decompression of spinal extradural metastases of liposarcoma.

Two patients with metastatic liposarcoma to the spine developed neurologic deficits that were successfully reversed by laminectomy and partial tumor resections. Recurrences at later dates were treated similarly with comparable outcomes. Paraplegia was forestalled for approximately two years by each of the surgical interventions.

Assessing damage in individual joints in rheumatoid arthritis: a new method based on the Larsen system.

OBJECTIVES: To evaluate observer agreement using the Larsen system (LS) and a Modified Larsen system (ML) when assessing individual joints of the hands and wrists in rheumatoid arthritis, and to compare the two systems. To determine the minimally important difference (MID) for the ML. METHODS: Thirty radiographs of hands and wrists from 10 patients who presented with RA were graded by two blinded observers, using the LS and then the ML. Patients were followed for a mean of 7.2 years (range: 4-10 years). Inter- and intra-observer agreement were calculated using the kappa statistic with linear incremental weights. Inter-observer agreement was also computed for the summed score, using an intraclass correlation coefficient. Inter-observer error was estimated by calculating the mean and standard deviation of the grading differences between the two observers. Prevalence of damage was calculated as a ratio of damage: no damage and expressed as a percentage. Pairs of radiographs were comparatively graded using a seven-point Likert scale. RESULTS: The kappa statistic for inter-observer agreement was 0.38 (marginal reproducibility) for the LS and 0.52 (good reproducibility) for the ML (P = 0.004). Using a difference of one grade as perfect agreement, it was 0.56 (good reproducibility) for the LS and 0.87 (excellent reproducibility) for the ML (P = 0.001). Intra-observer agreement was high in both systems. The distribution of ML-grade differences varied according to the level of the Likert scale: for "a little bit worse", representing the smallest amount of detectable damage progression, the distribution differences peaked around two grades. This value represented a MID 87% of the time. CONCLUSIONS: The LS lacks precision for individual joints. The ML, it is proposed, has more detailed definitions of grades, and is more reliable. When pairs of radiographs were compared, a two-grade difference on the ML was the MID.

Pseudarthrosis of the middle metacarpal following intramedullary fixation of a wrist arthrodesis.

We describe the case of a 36-year-old woman who presented with an unusual seronegative monoarthropathy of the right wrist and who was treated with fusion by the method of Clayton (1965). The patient probably sustained a metacarpal fracture during intramedullary Steinmann pin insertion, and subsequently developed a pseudarthrosis.

The Simmen classification of wrist destruction in rheumatoid arthritis. Experience in patients with early disease.

In this radiological study, bilateral radiographs of the wrist in 48 patients with early rheumatoid arthritis (RA) were graded by the Simmen classification, at different times, to determine its potential use in early disease. Interobserver agreement was good. The Simmen classification of wrist destruction in RA could be applied to the radiographs of approximately 50% of patients with early disease. It has some consistency over time.

Surgery of the hand in severe systemic sclerosis.

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5-9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint excisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed "finger-in-palm" deformities. Lesions of cutaneous calcinosis were removed in four patients. Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of nonunion. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.