Early benefits of a secondary fracture prevention programme.

INTRODUCTION: The most successful programme for secondary fracture prevention is the FLS (fracture liaison service) model. Our orthopaedic department carried out a prospective randomised study to measure the effectiveness of a 4-step intervention programme. The findings in this study reveal important additional clinical benefits to having an orthopaedic-based FLS programme and evaluates the usefulness of fracture risk tools. METHODS: We carried out a prospective study to evaluate patients with a fragility fracture of the hip. There were 2 groups, intervention and control (each 100 patients). Of these, 20 were either removed from the study or dropped out, leaving 180 for analysis. In addition to routine preoperative blood tests, albumin and thyroid function levels were obtained and PTH (parathyroid hormone) levels when indicated.The intervention group (83 patients) had a dual-energy x-ray absorptiometry (DEXA) scan performed and fracture risk (FRAX) was calculated. RESULTS: 12 patients (6.7%) had blood results which showed a potentially treatable cause for osteoporosis and 36 (20%) had blood results that changed their medical care.FRAX scores (180 patients) showed that the major osteoporotic fracture score correctly predicted the hip fracture in only 49%. The hip fracture score correctly predicted the hip fracture in 83%.DEXA scores (65 patients) showed osteoporosis in only 46% of hips and in only 26% of spines.An abnormal FRAX score or DEXA scan would have predicted a fragility fracture 93% of the time. CONCLUSIONS: In addition to reducing secondary fractures, FLS programmes can provide fundamental benefits to the health of the patient. The intervention programme in this study identified patients with underlying treatable causes, correctable clinical conditions and patients with an unusually low bone density. When used together, FRAX and DEXA are more sensitive predictors for hip fracture risk than either are individually. TRIAL REGISTRY: 201497CTIL (https://clinicaltrials.gov/ct2/show/NCT02239523).

Hyaluronic acid injections for chronic tennis elbow.

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.

Efficacy of orthopaedic-inspired osteoporosis management: a secondary fracture prevention program after a fracture of the hip in a prospective randomized study.

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 < 0.0001). CONCLUSION: Osteoporosis is a worldwide epidemic. Internationally, only about 20% of patients after a hip fracture are treated for their underlying weak bone. The most effective systems use a fracture liaison service (FLS) model. We present a 4-part intervention program that uses an FLS coordinator within the orthopaedic department. We encourage orthopaedic programs to adopt this or other models with the goal of taking the first step toward responsibility for bone health.An FLS program within an orthopaedic department can successfully initiate treatment for underlying osteoporosis.

A Rare Case of Median Nerve Entrapment within the Bone After Surgical Treatment of a Pediatric Supracondylar Humerus Fracture: A Case Report.

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.

Wrist Ganglia in Children: Nonsurgical Versus Surgical Treatment.

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.

Spontaneous Rupture of the Extensor Pollicis Longus Tendon With Repair and Contralateral Prophylactic Decompression: A Case Report and Review of the Literature.

Ruptures of the extensor pollicis longus (EPL) tendon are known to occur primarily from local mechanical causes at Lister's tubercle. Other reasons for ruptures have been proposed including local steroid or even distant steroid injections that might have weakened the tendon, leading to rupture. There have been rare cases in the literature that describe ruptures without any known causes. Here, we describe a case with no known risk factors and with a spontaneous EPL rupture on one side and subclinical tendinopathy on the other. The patient had the EPL repaired on the ruptured side and subsequent prophylactic decompression of the contralateral side. The side without the rupture had preoperative ultrasound and magnetic resonance imaging, and a synovial biopsy was interpreted as showing tendinopathy.