The High Burden of Acute and Chronic Pain in General Practice in French-Speaking Belgium.

Background: Chronic pain prevalence is very high in the general population, much higher than can be managed by chronic pain centers. Therefore, most pain patients are cared for by first-line professionals. However, general practitioners often feel ill at ease with these patients, and only a few studies assess the burden of chronic pain in general practice. To better estimate the resources needed to support these professionals, a good knowledge of (sub)acute and chronic pain prevalence and prognosis in general practices is needed. Methods: We report cross-sectional data from a larger longitudinal study performed in French-speaking general practices in Belgium in November 2018. Fifth-year medical students performing a one-month internship collected data for every third patient they saw each day: demographic information, pain characteristics, lifestyle, general health perception and the short Örebro Musculoskeletal Pain Screening Questionnaire in the French language. Results: 3882 patients (participation rate 66%) accepted to take part in the study. 22 and 50% of these suffered from (sub)acute and chronic pain, respectively. Pain was more often the motive of the consultation for (sub)acute than for chronic pain patients. Pain intensity and functional impact were moderate, irrespective of pain duration. 70% of (sub)acute and 31% of chronic pain patients were at low risk of chronicity. Conclusion: In our sample, chronic pain patients constituted 33-50% of patient contacts in general practice, indicating the high importance of providing adequate support to general practitioners and other first-line professionals, ie, by reinforcing collaboration with chronic pain centers.

Real-world care for individuals aged over fifty with fractures in France: Evidence for a wide care gap-The EPIFRACT Study.

OBJECTIVES: To describe the care trajectories of adults aged ≥50 years with fragility fractures in France. METHODS: A postal questionnaire was sent to 15,000 individuals aged ≥50 years extracted from a representative panel of the French population (METASKOPE) in April-May 2018. Respondents experiencing a single fragility fracture in the previous three years constituted the study population. Information was collected regarding diagnosis, hospitalisations, physician visits and treatment related to the fractures. RESULTS: 13,914 participants returned a questionnaire (92.8%), of whom 436 reported a single fragility fracture. Their mean age was 68.7±10.3 years. 11.9% of this sample had undergone bone densitometry (DXA) prior to the fracture and 11.9% had received a diagnostic of osteoporosis. Following the fracture, a further 17.4% underwent DXA and 8.5% were diagnosed with osteoporosis. 74.3% of fractures were initially managed in an emergency department and 29.6% led to immediate hospitalisation. Prior to fracture, 3.4% received a specific anti-osteoporotic treatment, 10.1% vitamin D and 6.4% calcium supplementation. After the fracture, these figures rose to 10.8%, 26.8% and 19.0% respectively. 86.2% participants made at least one follow-up visit to a physician. CONCLUSIONS: The rate of DXA screening following fragility fractures in subjects over fifty is very low. Most patients with fragility fractures did not receive a diagnosis of osteoporosis. The proportion of patients treated with a specific anti-osteoporotic treatment after a fracture is low even though around half consulted their general practitioner after the fracture. Practice guidelines are thus not being adhered to in everyday clinical practice in France.

Fragility fractures in France: epidemiology, characteristics and quality of life (the EPIFRACT study).

Between 1 and 2% of people aged 50 years and over living at home in France are likely to experience a fragility fracture each year. Three-quarters of these individuals are not diagnosed with osteoporosis and lose the opportunity for appropriate care. PURPOSE: To estimate the incidence of fragility fractures in France and to describe the characteristics of individuals with such fractures and of their fractures. METHODS: In April-May 2018, a postal survey was performed in France targeting a representative panel of 15,000 individuals aged ≥ 50 years, who were invited to complete a questionnaire. If they reported experiencing a fracture in the previous 3 years, they were asked to provide information on demographics, fracture type, risk factors for fractures and osteoporosis diagnosis. Only fragility fractures were considered, and these were classified as major (associated with increased mortality) or minor, based on the fracture site. RESULTS: Around 13,914 panellists returned an exploitable questionnaire (92.8%). About 425 participants reported ≥ 1 fragility fracture (453 fractures), corresponding to a 12-month incidence rate of 1.4% [95%CI: 1.2, 1.6]. Incidence was higher in women (1.99% [1.87, 2.05]) than in men (0.69% [0.38, 0.86]) and increased with age. Around 157 fractures (34.6%) were classified as major. Participants reporting major fractures were older than those reporting minor fractures (mean age: 72.6 ± 11.3 vs 67.1 ± 10.6) and more likely to report previous corticosteroid use (odds ratio: 1.90 [95%CI: 1.13, 3.18]). No other patient characteristic was associated with fracture severity. About 117 participants with fractures (27.5%) had undergone bone densitometry, and 97 (22.8%) declared having received a diagnosis of osteoporosis. CONCLUSIONS: Around 340,000 people aged ≥ 50 years living at home in France are estimated to experience osteoporotic fractures each year. However, > 75% of panellists reporting fractures were never diagnosed with osteoporosis and thus did not have the opportunity to receive appropriate care.

Is percutaneous pinning an outdated technique for distal radius fractures?

Distal radius fracture is a very common injury representing 17.5% of all fractures seen in the emergency room. However, the most effective treatment is still unclear and controversially debated. For ten years, we have been facing a true revolution by the increasing use of open reduction and fixation by volar locking plates as an alternative to previous less invasive treatment such as closed reduction and percutaneous k-wire pinning. Several meta-analyses have compared the clinical results after closed reduction and percutaneous pinning and volar locking plate fixation. Volar locking plate fixation achieves better early functional recovery, better radiological outcomes and less minor complications. However, long-term results were similar for both fixation methods. In addition, worse radiological outcomes and more minor complications after closed reduction and percutaneous pinning seem not to be clinically relevant. Interestingly, volar locking plate fixation continues to be a more dominant treatment method compared to percutaneous pinning in operative care of distal radius fractures. Surgeon characteristics such as age, profession as well as location and type of the clinic seem to play a role in the decision for the surgical treatment method. It appears that implant cost plays a minor role in treatment choice between closed reduction and percutaneous pinning and volar locking plate fixation.

2018 update of French recommendations on the management of postmenopausal osteoporosis.

OBJECTIVES: To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d'étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d'endocrinologie, and Société française de gériatrie et de gérontologie). METHODS: Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS). DISCUSSION AND CONCLUSION: The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.

Medication management after intramedullary nailing of atypical fractures.

Long term use of bisphosphonates (BPs) in osteoporotic patients may be associated with stress fractures of the sub-trochanteric and shaft area of the femur, so called "atypical" femoral fractures (AFF). Specific diagnosis criteria have been defined with 5 major features; the presence of four of them characterizes the AFF. Once a complete fracture occurred, the best surgical treatment is closed reduction and intra medullary nailing. The BPs treatment should be stopped immediately after an AFF occurred. Dietary calcium and vitamin D status should be assessed, and adequate supplementation prescribed. Principle of combination of a systematic bone anabolic treatment is strongly debated. The recombinant parathyroid hormone 1-34 or Teriparatide ® (TPTD) has an anabolic effect on bone and prevent osteoporotic fractures. Available preclinical and clinical data have also demonstrated the role played by TPTD to enhance bone fracture healing and the potential beneficial effect in impaired fracture healing or specific clinical condition like AFFs. Some authors have proposed in incomplete BP use stress fractures different medical management according the MRI findings. Bone anabolic agents may be promising both to prevent healing complications in AFFs and to promote healing in conservative treatment of incomplete AFFs. More clinical studies are needed to confirm this hypothesis.

Unmet needs and current and future approaches for osteoporotic patients at high risk of hip fracture.

This review provides a critical analysis of currently available approaches to increase bone mass, structure and strength through drug therapy and of possible direct intra-osseous interventions for the management of patients at imminent risk of hip fracture. PURPOSE: Osteoporotic hip fractures represent a particularly high burden in morbidity-, mortality- and health care-related costs. There are challenges and unmet needs in the early prevention of hip fractures, opening the perspective of new developments for the management of osteoporotic patients at imminent and/or at very high risk of hip fracture. Amongst them, preventive surgical intervention needs to be considered. METHODS: A European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)/International Osteoporosis Foundation (IOF) working group reviewed the presently available intervention modalities including preventive surgical options for hip fragility. This paper represents a summary of the discussions. RESULTS: Prevention of hip fracture is currently based on regular physical activity; prevention of falls; correction of nutritional deficiencies, including vitamin D repletion; and pharmacological intervention. However, efficacy of these various measures to reduce hip fractures is at most 50% and may need months or years before becoming effective. To face the challenges of early prevention of hip fractures for osteoporotic patients at imminent and/or at very high risk of hip fracture, preventive surgical intervention needs further investigation. CONCLUSION: Preventive surgical intervention needs to be appraised for osteoporotic patients at imminent and/or at very high risk of hip fracture.

Fracture repair: general aspects and influence of osteoporosis and anti-osteoporosis treatment.

Bone differs from other tissues in its capacity to self-repair after a fracture. The low bone mass and structural deterioration of bone associated with osteoporosis increases the risk of fragility fracture compared with healthy individuals. The intention of this article is to review the complex process of fracture repair and essential requirements for a successful fracture healing response summarized as the "diamond concept" in terms of aging and osteoporosis. The current preclinical and clinical evidence for a beneficial or harmful influence of anti-osteoporosis medications such as bisphosphonates, parathyroid hormone (PTH), strontium ranelate and antibodies of Wnt-inhibiting signaling proteins on bone healing is presented and discussed. Literature suggests that there are no detrimental consequences of such therapeutics on fracture repair processes. Following a fragility fracture, it seems that early start of preventive anti-osteoporotic treatment right after surgery does not delay the union of the fracture, except perhaps in the case of very rigidly fixed fracture requiring direct bone healing. There is some promising experimental and clinical evidence for possible enhancement of the bone repair process via administration of systemic agents. Further well designed studies in humans are necessary to accumulate more evidence on the positive effects and to translate this knowledge into valid therapeutic applications.

Bilateral Second Carpal Row Duplication Associated with Multiple Epiphyseal Dysplasia.

We report a case of a 75-year-old woman presenting a hitherto undescribed condition of bilateral second carpal row duplication. She was diagnosed in childhood with both Marfan and Ehlers-Danlos syndromes, with no clear evidence and no further medical follow-up. She presented throughout her life with various articular symptoms, which appeared to be compatible with a diagnosis of multiple epiphyseal dysplasia, and underwent several surgical procedures on her knees and hips. Most recently, she was reporting pain at the base of the fifth metacarpal bone of the left hand. X-ray images and computed tomography (CT) were obtained for exploration and showed a total second row duplication in both carpi, with a total number of 18 carpal bones in each wrist.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit.

AIM: To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit. METHODS: A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated. RESULTS: During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07). CONCLUSION: The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Trabecular Bone Score: Where are we now?

The Trabecular Bone Score is a rather new index obtained at the lumbar spine at the same time as a real bone mineral density. It was developed to reflect bone microarchitecture. It was proposed to be easily used in everyday practice as a surrogate of bone strength. Our aim was to review 1. technical points such as correlations between Trabecular Bone Score and bone microarchitectural parameters, Trabecular Bone Score and bone strength, the effects of dual-energy X-ray absorptiometry image spatial resolution, age, macroarchitecture, body mass index, and osteoarthritis, on Trabecular Bone Score, and 2. evidences to use Trabecular Bone Score for separating individuals with fragility fractures from controls, predicting fragility fractures, and for longitudinally monitoring changes related to treatments. Correlations between Trabecular Bone Score and bone microarchitectural parameters vary widely across bone sites, microarchitectural parameters, and study designs. In vivo, the Trabecular Bone Score explains little of the variance in trabecular microarchitectural parameters. We emphasize that it is a texture parameter. The Trabecular Bone Score is reduced in patients with fragility fracture. Several retrospective and prospective studies have shown its discriminative ability regarding the fracture risk. When combining the areal Bone mineral Density and Trabecular Bone Score, the Trabecular Bone Score remains a predictor of fracture but not the areal Bone Mineral Density. However in prospective studies, the best predictor of fracture remains hip areal bone mineral density. Due to the lack of evidence, we recommend not to use Trabecular Bone Score for following patients treated by anti-osteoporotic drugs.

Usefulness of bone density measurement in fallers.

The objective of this systematic literature review is to discuss the latest French recommendation issued in 2012 that a fall within the past year should lead to bone mineral density (BMD) measurement using dual-energy X-ray absorptiometry (DXA). This recommendation rests on four facts. First, osteoporosis and fall risk are the two leading risk factors for nonvertebral fractures in postmenopausal women. Second, BMD measurement using DXA supplies significant information on the fracture risk independently from the fall risk. Thus, when a fall occurs, the fracture risk increases as BMD decreases. Third, osteoporosis drugs have been proven effective in preventing fractures only in populations with osteoporosis defined based on BMD criteria. Finally, the prevalence of osteoporosis is high in patients who fall and increases in the presence of markers for frailty (e.g., recurrent falls, sarcopenia [low muscle mass and strength], limited mobility, and weight loss), which are risk factors for both osteoporosis and falls. Nevertheless, life expectancy should be taken into account when assessing the appropriateness of DXA in fallers, as osteoporosis treatments require at least 12months to decrease the fracture risk. Another relevant factor is the availability of DXA, which may be limited due to geographic factors, patient dependency, or severe cognitive impairments, for instance. Studies are needed to better determine how the fall risk and frailty should be incorporated into the fracture risk evaluation based on BMD and the FRAX® tool.

The mini postero-postero-lateral mini incision in total hip arthroplasty.

PURPOSE: Mini invasive incisions in THA and femoral hip prostheses tend to minimise healing and recovery time. We have used a very posterior approach with technical modifications and precise skin landmarks to decrease surgical complexity, and we describe this experience here. METHODS: From 2010 to 2012, 140 patients aged 79 years (range 53-93 years) were operated upon by the same surgeon in a continuous series using the same minimally invasive skin incision and six different types of implants. The incision was very posterior in the hip allowing direct visualisation of the acetabulum in the hip flexion position and visualisation of the femoral shaft extremity in a leg flexion position. RESULTS: The mean operating time was 100 minutes (range 75-110 min). Estimated blood loss was 385 cc (20-585 cc). Twenty-six patients had blood transfusion. The mean hospital stay was 6.8 days (5-20 days) including the time waiting for a rehabilitation centre. No operative complications related to the technique were recorded. On the postoperative radiograph, the femoral stem was aligned with the femoral axis within 3° in all patients. The mean acetabular angle to the ground plane was 40° (35-48°). No patient had a leg length discrepancy of more than four millimetres. The mean skin incision length was seven centimetres (six to eight centimetres). All patients were seen at the clinic after six weeks and the data were unchanged at this time point. CONCLUSION: The method and skin landmarks we describe appear to be a safe way to perform minimally invasive total hip replacement.

Balloon treatment of posterior shoulder dislocation with reverse Hill-Sachs injury: description of a new technique.

PURPOSE: Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as "reverse Hill-Sachs lesions" may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation. METHODS: From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior "reverse Hill-Sachs" impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up. RESULTS: At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation. CONCLUSION: Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.

Balloon reduction and cement fixation in calcaneal articular fractures: a five-year experience.

PURPOSE: Balloon reduction and cement fixation of displaced articular fractures of the calcaneus have been described elsewhere but support for it lacks clinical evidence. We have been performing the technique since October 2006 and describe here our clinical experience including three to five-year follow up of our first ten cases with no patient lost to follow up. METHODS: From September 2006 to September 2009, ten patients were admitted with a calcaneus fracture, six were female and four male, one case was bilateral (11 fractures). Patients were operated upon in the prone position according to the technique we have described. Reduction was obtained in all cases. Patients were discharged after an average of four days postoperatively and were allowed weight bearing after two to three months. All patients were followed up regularly and were examined by an independent observer at the latest follow up. The clinical results were assessed using the AOFAS ankle score, the Babin score and the RAND-36 physical components score. A CT scan was obtained in all patients before, after the operation and at the latest follow up. RESULTS: After a minimal follow up of 36 months (three to five years), no patient was lost to follow up and none required further surgery. The AOFAS clinical results were rated good or excellent in 81.8 % of cases (nine fractures, eight patients), and the physical component of the RAND-36 was 74.6. One patient only (one fracture) had a bad clinical result and evidence of subtalar arthritis on the CT scan and was offered a subtalar fusion; she refused. All patients had returned to their former professional activities at the same level as before the fracture except one who had retired but had resumed leisure walking. CONCLUSION: Balloon reduction and cement fixation of fresh calcaneal fractures ("balloon calcaneoplasty") appears a safe and effective procedure in a variety of calcaneal fractures with lasting and excellent clinical results. More studies are needed to further refine the indications and the limits of the procedure.

2012 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis.

OBJECTIVES: To update the evidence-based position statement published by the French National Authority for Health (HAS) in 2006 regarding the pharmacological treatment of postmenopausal osteoporosis, under the auspices of the French Society for Rheumatology and Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), and with the participation of several learned societies (Collège National des Gynécologues et Obstétriciens Français, Groupe d'Étude de la Ménopause et du Vieillissement hormonal, Société Française de Chirurgie Orthopédique, Société Française d'Endocrinologie, and Société Française de Gériatrie et de Gérontologie). METHODS: A multidisciplinary panel representing the spectrum of clinical specialties involved in managing patients with postmenopausal osteoporosis developed updated recommendations based on a systematic literature review conducted according to the method advocated by the HAS. RESULTS: The updated recommendations underline the need for osteoporosis pharmacotherapy in women with a history of severe osteoporotic fracture. In these patients, any osteoporosis medication can be used; however, zoledronic acid is the preferred first-line medication after a hip fracture. In patients with non-severe fractures or no fractures, the appropriateness of osteoporosis pharmacotherapy depends on the bone mineral density and FRAX(®) values; any osteoporosis medication can be used, but raloxifene and ibandronate should be reserved for patients at low risk for peripheral fractures. Initially, osteoporosis pharmacotherapy should be prescribed for 5 years. The results of the evaluation done at the end of the 5-year period determine whether further treatment is in order. CONCLUSIONS: These updated recommendations are intended to provide clinicians with clarifications about the pharmacological treatment of osteoporosis.