Use of Fortified Bread for Addressing Vitamin D Deficiency.

Vitamin D deficiency due to inadequate sun exposure and/or inadequate intake from food is very common worldwide, consisting a major public health problem. As prolonged exposure to ultraviolet radiation involves risks, food fortification of staple foods emerges as a favorable solution for addressing vitamin D deficiency. Bread is a suitable candidate for fortification as it is consumed often and is the main carbohydrate source in European countries.The purpose of this study was the evaluation of the bioavailability of vitamin D from a fortified Greek-type bread that was developed as a means for addressing vitamin D deficiency, by comparing the absorption curve of vitamin D in fortified bread in relation to that of plain vitamin supplementation. Two groups of clinically healthy volunteers consumed 25,000 international units (IU) of vitamin D3 (cholecalciferol) either in fortified bread (Group A) or in a plain supplement form (Group B). The baseline plasma concentrations of cholecalciferol were 8.1 ± 6.0 ng/mL and 6.8 ± 3.4 ng/mL in Groups A and B, respectively. After 12, 24, and 48 h, the concentrations of cholecalciferol in Group A were 16.7 ± 4.8, 15.3 ± 8.3 and 11.9 ± 6.0 ng/mL, respectively, and in Group B, 15.2 ± 3.3, 11.6 ± 2.4, and 9.6 ± 3.6 ng/mL, respectively. In both groups, the concentrations of cholecalciferol at 12 and 24 h were significantly higher than the baseline concentrations (p < 0.01). There were no statistically significant differences between the concentrations of cholecalciferol between Groups A and B, at each time point.Cholecalciferol is bioavailable from Greek-type fortified bread and bread could be used for addressing vitamin D deficiency.

Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.

Thumb duplication: molecular analysis of different clinical types.

PURPOSE: Molecular analysis of different types of thumb duplication and identification of new suspected gene mutations. MATERIALS AND METHODS: In a series of patients operated for polydactyly, DNA was extracted from blood samples collected preoperatively. Among these, the samples of two patients with thumb duplication (Wassel types III and IV) were initially selected for molecular analysis. The method of Clinical Exome Solution was used for the study of the phenotype-involved genes. Next-generation sequencing (NGS) was performed on a NextSeq-500 Platform (Illumina), and Sophia DDM® SaaS algorithms were used for the bioinformatics analysis of the data. RESULTS: In total, 8-including 4 new-mutations were detected in CEP290 (1 mutation), RPGRIP1 (2 mutations), TMEM216 (2 mutations), FBN1 (1 mutation), CEP164 (1 mutation), and MEGF8 (1 mutation) genes. NGS revealed 3 mutated genes in the patient with Wassel III thumb duplication and 5 mutated genes in the patient with Wassel IV duplication. The molecular analysis revealed that the patients had 2 mutated genes in common, but they only shared one common mutation. CONCLUSION: The new detected mutations are most probably associated with thumb duplication, as they belong to genes with already described mutations causing ciliopathies, often including polydactyly in their phenotype. Recognition of these mutations will be helpful to prenatal diagnosis, operative treatment strategy prediction, and possible future experimental applications in gene therapy.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

PURPOSE: To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. MATERIALS AND METHODS: Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. RESULTS: In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. CONCLUSION: 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Great trochanter bursitis vs sciatica, a diagnostic-anatomic trap: differential diagnosis and brief review of the literature.

PURPOSE: The purpose of this study is to point out the difficulty of differentiating great trochanter bursitis (GTB) from sciatica and estimating the prevalence of GTΒ, in patients poorly diagnosed with sciatica in their first visit to the general practitioner and referred to a spine infirmary. METHODS: The diagnosis of GTΒ was made based on history and physical examination, and was confirmed by ultrasonography and/or response to an anesthetic plus corticosteroid injection to the trochanteric bursa. Demographic and clinical characteristics of the study group were evaluated. The statistical analysis was held with the SPSS pc package (version 24.0). RESULTS: In a total of 657 referrals for sciatica, 72 patients (10.95%) were incorrectly diagnosed as suffering from sciatica, whereas, in fact, they were suffering from GTΒ. In addition, 18 patients (2.74%) were diagnosed as suffering from persistent sciatica with coexisting GTΒ. More women than men had GTΒ (79-11). Mean age for patients with sciatica diagnosis but suffering from GTΒ was 60 years. Mean age for patients with both sciatica and GTΒ was 61 years. CONCLUSIONS: The GTB is a common clinical entity in middle-aged women, which can escape from the physician in cases of incomplete medical history and clinical examination, leading to unnecessary imaging tests and treatment approaches, burdening both the patient and the health system. Early diagnosis of GTB may dramatically reduce cost, prevent unwanted and inappropriate imaging exams and treatment, and make the patient free of symptoms immediately. These slides can be retrieved under Electronic Supplementary Material.

Magnetic resonance morphometry of the adult normal lumbar intervertebral space.

PURPOSE: This study aims to: (a) quantify and evaluate normal relationships between neighboring spinal units using MR imaging indices, (b) propose an easy-to-apply-and-reproduce method of estimating the correct amount of distraction when surgically restoring a collapsed intervertebral disc, based on individualized measurements. METHODS: This is a retrospective cross-sectional MR imaging study of 119 adult subjects, aged 18-54, asymptomatic for low back pain. Each of the examinees should demonstrate two or more consecutive intervertebral discs classified as Pfirrmann grade I or II to be included. We measured and studied the relationships of disc height index, Dabbs index, Farfan index, disc convexity index and mean and posterior disc height per spinal level using multiple regression analysis. All measurements were tested for intra- and interobserver agreement by two raters. RESULTS: DHI, Dabbs, Farfan, and mean disc height had a statistically significant correlation with the spinal level and age. Our results were highly reproducible, with excellent inter- and intraobserver agreement and reliability between two raters (ICC = 0.992 and 0.994, respectively). Furthermore, we expressed each intervertebral space as a percentage of its adjacent space, introducing the coefficient α factor for every intervertebral space. CONCLUSIONS: Our results suggest that a normal values' database to refer during preoperative planning of correction of a degenerated intervertebral disc is feasible. Our study offers new anatomical and radiological insight in terms of spinal measurements and their potential correlation with current surgical techniques. A new approach for calculating disc space as an expression of its adjacent disc has been introduced with various potential applications.

Upper extremity vascular injuries: Etiology, management and outcome.

BACKGROUND: Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population. They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations. Their management is challenging since they can lead to disabilities with major socioeconomic effects. AIM: To analyze data about the mechanism of injury, the management algorithm and functional outcomes of vascular injuries of the upper extremity. METHODS: One hundred and fifteen patients (96 males and 19 females) with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted. Mean patients' age was 33.7 years and the mean follow up time was 7.4 years. Patients with Mangled Extremity Severity Score ≥ 7 and Injury Severity Score ≥ 20, previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded, from the study. RESULTS: A penetrating trauma was the most common cause of injury. The radial artery was the artery injured in most of the cases (37.4%) followed by the ulnar (29.5%), the brachial (12.1%) and the axillary (6%). A simultaneous injury of both of the forearm's arteries was in 15.6% of the cases. In 93% of the cases there were other concomitant musculoskeletal injuries of the extremity. Tendon lacerations were the most common, followed by nerve injuries. The postoperative functional scores (full Disabilities of the Arm, Shoulder, and Hand and VAS) had very satisfactory values. CONCLUSION: Although vascular injuries of the upper extremity are rare, they may occur in the context of major combined musculoskeletal trauma. Although a multidisciplinary approach is essential to optimize outcome, the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma, excluding isolated vascular injuries, ensures shorter operative times and better functional outcomes.

Pediatric terrible triad elbow fracture dislocations: report of 2 cases.

An elbow dislocation associated with radial head and coronoid process fractures, the terrible triad injury, has an unpredictable outcome in adults and is rare in children. We present 2 such injuries in children, 1 combined with an olecranon fracture, and both with good early clinical outcomes. However, in 1 of the 2 cases, avascular necrosis of the proximal radius was evident on radiographs.

MiR-217 Regulates SIRT1 Expression and Promotes Inflammatory and Apoptotic Responses in Osteoarthritis.

Previous studies have reported miR-217 uregulation in age-related pathologies. We investigated the impact of miR-217-5p on sirtuin 1 (SIRT1) regulation in human osteoarthritic (OA) chondrocytes. MiR-217 target enrichment analyses were performed using three public databases, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes. MiR-217-5p expression levels were quantified in normal and OA chondrocytes. SIRT1 expression levels, nuclear factor kappa-B p65 subunit (NF-κBp65) and p53 acetylation levels, and expression levels of OA-related pro-inflammatory markers [tumor necrosis factor α (TNFα), interleukin 1ß (IL-1ß), IL-6], pro-apoptotic markers [Bax, pro-caspase 3, cleaved caspase 3] and matrix regulators [matrix metalloproteinase (MMP)-1, MMP-13, MMP-9, Collagen 2 (COL2A1), Aggrecan (ACAN)] were evaluated in miR-217 mimic-treated and/or miR-217 inhibitor-treated OA chondrocytes, with/without subsequent treatment with siRNA against SIRT1 (siSIRT1). MiR-217-5p was upregulated in OA chondrocytes, while target prediction/enrichment analyses revealed SIRT1 as miR-217 target-gene. Deacetylation of NF-κBp65 and p53 in miR-217 inhibitor-treated OA chondrocytes was reversed by siSIRT1 treatment. MiR-217 inhibitor-treated OA chondrocytes showed increased COL2A1, ACAN and decreased IL-1ß, IL-6, TNFα, Bax, cleaved caspase 3 and MMPs expression levels, which were reversed following miR-217 inhibitor/siSIRT1 treatment. Our findings highlight the impact of miR-217-5p on SIRT1 downregulation contributing to OA pathogenesis.

Update in combined musculoskeletal and vascular injuries of the extremities.

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient's medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Medico-legal risks associated to hand and wrist trauma.

BACKGROUND: Acute hand and wrist injuries are common and may lead to long-term disability if not managed adequately. Claims for negligence have been increasing in medical practice over the past few decades, with hand and wrist injuries and their treatment representing a significant percentage of orthopedic surgery lawsuits. There is no available literature regarding medical malpractice claims in hand and wrist injuries and surgery in Greece. AIM: To identify claims related to hand and wrist trauma and surgery and to define the reasons of successful litigations. METHODS: We performed a retrospective study of all legal claims of negligence for hand and upper extremity surgery that went to a trial, attributed to all surgical specialties, in Greece for a 20-year period. Data was further analyzed to identify claims related to hand and wrist trauma and surgery. RESULTS: There were six malpractice claims related to hand and wrist trauma that ended in a trial. A missed diagnosis, which resulted in failure of initial management of the injury, was the main reason for a claim. Three of the six cases resulted in complete or partial loss of a finger. Two cases are still open, requiring an expert witness's report, two cases were closed in favor of the defendant, and two cases were closed in favor of the plaintiff with a mean compensation of €2000 (€1000-€3000). CONCLUSION: Missed diagnosis was the main reason for a malpractice claim. Better understanding of factors leading to successful claims will help surgeons improve their practice to minimize legal implications and litigation.

Anatomy Learning from Prosected Cadaveric Specimens Versus Plastic Models: A Comparative Study of Upper Limb Anatomy.

Human cadaveric prosections are a traditional, effective, and highly appreciated modality of anatomy learning. Plastic models are an alternative teaching modality, though few studies examine their effectiveness in learning of upper limb musculoskeletal anatomy. The purpose of this study is to investigate which modality is associated with a better outcome, as assessed by students' performance on examinations. Overall, 60 undergraduate medical students without previous knowledge of anatomy participated in the study. Students were assigned into two groups. Group 1 attended lectures and studied from cadaveric prosections (n = 30) and Group 2 attended lectures and used plastic models in the laboratory (n = 30). A knowledge assessment, including examination with tag questions (spot test) and written multiple-choice questions, was held after the end of the study. Students' perceptions were also investigated via an anonymous questionnaire. No significant difference in students' performance was observed between the group using prosections and the group using plastic models (32.2 ± 14.7 vs 35.0 ± 14.8, respectively; P = 0.477). Similarly, no statistically significant difference was found regarding students' satisfaction from using each learning modality (P = 0.441). Plastic models may be a valuable supplementary modality in learning upper limb musculoskeletal anatomy, despite their limitations. Easy to use and with no need for maintaining facilities, they are highly appreciated by students and can be useful when preparing for the use of cadaveric specimens.

Donor sites for pedicled skeletal grafts of the hand, wrist, and forearm.

Pedicled bone and periosteal grafts provide successful reconstruction of skeletal problems of the distal radius, wrist, and hand. The purpose of this study was to evaluate the available alternatives and to propose the most suitable skeletal grafts for the reconstruction of the distal radius, and the carpal and hand bones. The alternative donor sites (dorsal and palmar distal radius, and metacarpals), their pedicles, and the potential coverage area in relation to specific wrist and hand pathology were determined in the cadaveric dissections. In the clinical setting, 75 pedicled grafts were used for the treatment of scaphoid nonunions (62 cases), lunate necrosis (8 cases), reconstruction of the metacarpal defects (2 cases), and wrist fusions (3 cases). All alternatives have the advantage of a single approach that may be performed under tourniquet control, from the same team. Among the available alternatives, surgeon's familiarity plays the most important role for the final selection of the graft.

Triple nerve block at the knee for foot and ankle surgery performed by the surgeon: difficulties and efficiency.

BACKGROUND: Combined nerve blocks at the knee can provide safe anesthesia below the knee avoiding the potential complications of general or spinal anesthesia while reducing the need for opioids in the postoperative period. This study presents the outcomes of a large series of patients that underwent foot and ankle surgery receiving a triple nerve block at the knee. MATERIALS AND METHODS: Three hundred eighty patients underwent foot and ankle surgery receiving anesthesia with triple nerve block at the knee (tibial, common peroneal and saphenous nerve). Surgery included a variety of bone and soft tissue procedures. The nerve block was performed by an orthopaedic surgeon in the lateral decubitus position. RESULTS: The successful nerve block rate was 91 percent. There was no need to convert to general or spinal anesthesia, although 34 patients (9%) needed additional analgesia intraoperatively. Complete anesthesia required 25 to 30 minutes from the time of performing the block. No complication occurred secondary to the use of the anesthetic agent (ropivacaine 7.5%). Postoperative analgesia lasted from 5 to 12 hours, reducing the need of additional analgesics. Hospitalization averaged 1.4 days (from 0 to 5) with the majority of patients discharged the day after the operation (248/380). A high satisfaction rate was reported by the patients with no adverse effects and complications. CONCLUSION: We found triple nerve block at the knee to be a safe and reliable method of regional anesthesia providing low morbidity, high success rate, long acting analgesia, and fewer complications than general or spinal anesthesia. It is a simple method that can be performed by the orthopaedic surgeon.

Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis: 26 hips followed for an average of 3 years.

BACKGROUND AND PURPOSE: Tantalum rod implantation has recently been proposed for treatment of early stages of femoral head osteonecrosis.The purpose of our study was to report the early results of its use in pre- and post-collapse stages of the disease. METHODS: We studied prospectively 27 patients who underwent tantalum rod implantation for treatment of nontraumatic femoral head osteonecrosis between December 2000 and September 2005. Patients were evaluated radiologically and clinically using the Steinberg classification and the Harris hip score (HHS). Disease stage varied between stages II and IV. Mean follow-up time was 38 (15-71) months. RESULTS: 1 patient (1 hip) died 15 months after surgery for reasons unrelated to it. 13 of 26 hips remained at the same radiographic stage, and 13 deteriorated. Mean HHS improved from 49 to 85. 6 patients required conversion to total hip arthroplasty. When the procedure was used for stages III and IV, both radiological outcome and revision rates were worse than for the stage II hips. There was, however, no difference in postoperative HHS between patients at pre- and post-collapse stages at the time of initial evaluation. Survivorship, with revision to THA as the endpoint,was 70% at 6 years. INTERPRETATION: The disease process does not appear to be interrupted,but there was a significant improvement in hip function initially in most hips. Tantalum rod implantation is a safe "buy-time" technique, especially when other joint salvage procedures are not an option. Appropriate patient selection and careful rod insertion are needed for favorable results.

Scaphoid nonunions in adolescents: Treatment with vascularized bone grafts.

INTRODUCTION: Scaphoid nonunions (SN) are rare in adolescents. The use of vascularized bone grafts (VBG) from the distal radius as an alternative to conventional grafting for the treatment of established SN in adolescents is described. PATIENTS AND METHODS: The technique was applied in 13 patients with symptomatic SN resulting from fractures. All patients were male with average age of 16.5 years (15-17.5). The average period from injury to surgery was 8.3 months (4-13). Patients underwent vascularized bone grafting and internal fixation with K-wires. In 6 patients with proximal pole nonunion a VBG from the dorsal distal radius was used, and in 7 with a waist nonunion a VBG from the palmar distal radius was used. The valuation was clinical (grip strength, range of motion, VAS pain score, DASH) and radiographic. The time to return to activity was also recorded. RESULTS: The mean follow-up was 9.8 years (range, 4-16). The union rate was 100% (11/11 cases). Union was achieved in a mean period of 7.2 weeks (range, 6-10), without growth disturbance or other complications from the epiphyseal plate of the distal radius. The range of motion and grip strength was 89% and 92% of the contralateral respectively. The mean postoperative DASH score was 8 and the VAS score was 1. All patients returned to daily activities and sports in a mean period of 4.5 months. CONCLUSIONS: The use of VBG from the distal radius provided a permanent solution in the rare case of SN in adolescents, without donor site morbidity or epiphyseal plate disturbance. The deformity and carpal height were corrected resulting in painless motion and grip strength.

Clinical and epidemiological features of upper-extremity infections caused by Staphylococcus aureus carrying the PVL gene: a four-year study in Greece.

BACKGROUND: All Staphylococcus aureus isolated during 2003-2006 at a university hospital in Thessalia, central Greece, from ulcerative upper-extremity infections were tested for the presence of PVL gene and for possible clonal relationship to validate the role of PVL toxin in the clinical features of these infections and also to establish preventive measures towards limiting the spread of such strains among close contacts. MATERIAL/METHODS: Of 305 bacterial cultures obtained from consecutive patients suffering from purulent musculoskeletal infections of an upper extremity, 207 revealed the presence of S. aureus (81 methicillin-resistant and 126 methicillin-sensitive). Seventy of the 207 cultures were found to be positive for the PVL gene. RESULTS: The PVL gene was detected in 12.1% (2003), 46.7% (2004), 34% (2005), and 53% (2006) of upper-extremity staphylococcal infections, indicating a statistically significant increase between 2003 and 2004-2006. However, there was a significant decrease in readmissions during 2005 and 2006 and also in the number of relatives diagnosed with PVL-positive infections during the same period of time. The localization of these infections, their higher incidence during summer, and the transmission to family members indicated that contact was the means of spread of PVL-positive S. aureus. Most isolates belonged to the ST-80 clone, predominant in Europe. CONCLUSIONS: The emergence of new MRSA and also MSSA clones carrying the PVL gene and the decreases in readmissions and number of infected "close contacts" emphasizes the need for closer systematic surveillance and the implementation of preventive measures.

The 12-in-1 procedure for the treatment of congenital idiopathic clubfoot.

The purpose of this study was to assess the long-term results of an extended soft tissue release in a single procedure, for the treatment of congenital idiopathic clubfoot. Seventeen patients with 22 congenital idiopathic clubfeet were treated surgically with the 12-in-1 procedure. The majority of cases were grade III (severe) deformities. The procedure consisted of dividing or lengthening 12 elements of the posterior, medial, and plantar side of the foot. The mean follow-up period was 11 years (range, 7-18 years). Revision surgery was required within 1 to 3.5 years of the initial procedure in four cases (residual deformity), whereas in another patient, bilateral camptodactyly was corrected 11 years postoperatively. At the time of the most recent follow-up, and after the revision procedures in patients with residual or recurrent deformities, results were excellent in 8 and good in 14 cases. The long-term follow-up results of the 12-in-1 procedure are encouraging for the treatment of idiopathic congenital clubfoot.

Quality of life and psychological consequences in elderly patients after a hip fracture: a review.

Fractures due to fragility of the bone around the hip joint have become a major public health issue, presenting with an increasing incidence due to the growth of the elderly population. The purpose of this review was to evaluate the impact of hip fractures on the quality of life (QoL), health status (HS), functioning, and psychological parameters, and factors influencing the outcome and the appropriate interventions for improvement of elderly patients. A systematic electronic search of the relevant literature was carried out using the CINAHL, Cochrane, EMBASE, Medline (OvidSP), and PubMed databases spanning the time period from their establishment up to January 2017. Forty-nine randomized controlled trials or prospective cohort studies reporting the QoL and psychological outcomes were assessed by using standardized questionnaires. Patients with a hip fracture who were older than 65 years, were included in the analysis. In the majority of elderly patients, the hip fracture seriously affected physical and mental functioning and exerted a severe impact on their HS and health-related QoL (HRQoL). Moreover, most of the patients did not return to prefracture levels of performance regarding both the parameters. The levels of mental, physical, and nutritional status, prior to the fracture, comorbidity, and female gender, in addition to the postoperative pain, complications, and the length of hospital stay, were the factors associated with the outcome. Psychosocial factors and symptoms of depression could increase pain severity and emotional distress. For the displaced femoral neck fractures, the treatment with total hip arthroplasty or hemiarthroplasty, when compared to the treatment with internal fixation, provided a better functional outcome. Supportive rehabilitation programs, complemented by psychotherapy and nutritional supplementation prior to and after surgery, provided beneficial effects on the HS and the psychosocial dimension of the more debilitated patients' lives. Lack of consensus concerning the most appropriate HRQoL questionnaires to screen and identify those patients with more difficulties in the psychosocial functions, demonstrates the necessity for further research to assess the newer outcome measurement tools, which might improve our understanding for better care of patients with hip fractures.