Health-Related Quality of Life after Fractures of the Distal Forearm in Children and Adolescents-Results from a Center in Switzerland in 432 Patients.

(1) Background: We aimed to evaluate the health-related quality of life (HRQoL) in children with fractures of the distal forearm and to assess if HRQoL was associated with fracture classification; (2) Methods: We followed up on 432 patients (185 girls, 247 boys) who sustained a fracture of the distal radius or forearm from 1/2007 to 6/2007, 1/2014 to 6/2014, and 11/2016 to 10/2017. Patients filled in the Quick-DASH (primary outcome) and the Peds-QL; (3) Results: The radius was fractured in 429 and the ulna in 175 cases. The most frequent injury of the radius was a buckle fracture (51%, mean age 8.5 years), followed by a complete metaphyseal fracture (22%, 9.5 years), Salter-Harris-2 fracture (14%, 11.4 years), greenstick fracture (10%, 9.3 years), Salter-Harris-1 fracture (1%, 12.6 years), and other rare injuries. The most common treatment was closed reduction and an above-elbow cast in 138 cases (32%), followed by a cast without reduction (30%), splint (28%), and K-wire fixation and cast (9%). Definite treatment was performed initially in 95.8%, a new cast or cast wedging was performed in 1.6%, and revision surgery was performed in 2.5%. There were no open reductions and no plate fixations. After a mean follow-up of 4.2 years, patients with buckle fractures had a mean Quick-DASH of 3.3 (scale of 0-100) (complete fracture: 1.5; greenstick: 1.5; SH-1: 0.9; SH-2: 4.1; others: 0.9). The mean function score of the PedsQL ranged from 93.0 for SH-2 fractures to 97.9 for complete fractures; (4) Conclusions: In this cohort of 432 children with fractures of the distal forearm, there was equally good mean mid- and long-term HRQoL when assessed by the Quick-DASH and the PedsQL. There was a trend for children with complete metaphyseal fractures reporting better HRQoL than patients with buckle fractures or patients with Salter-Harris II fractures, however, these differences were not statistically significant nor clinically relevant.

Health-Related Quality of Life after Adolescent Fractures of the Femoral Shaft Stabilized by a Lateral Entry Femoral Nail.

(1) Background: In adolescents, fractures of the femoral shaft that are not suitable for elastic-stable-intramedullary-nailing (ESIN), are challenging. We aimed to evaluate the health-related quality of life (HRQoL) and complications in adolescents treated with intramedullary rodding using the adolescent lateral trochanteric entry femoral nail (ALFN), and to assess if HRQoL was associated with additional injuries. (2) Methods: We followed-up on 15 adolescents with a diaphyseal femoral fracture who were treated with an ALFN from 2004 to 2017. Patients were asked to fill in a questionnaire that includes the iHOT, Peds-QL, and the Pedi-IKDC. (3) Results: The ALFN was used as a primary method of fixation in 13 patients, and as a fixation for failed ESIN in two cases. All 15 fractures healed radiographically. One distal locking screw broke. After a mean follow-up of 2.8 years, the mean iHOT-12 was 14.0 (SD 15.4), PedsQL-function was 85.7 (SD 19.3), PedsQL-social-score was 86.2 (SD 12.5), and the mean Pedi-IKDC was 77.2 (SD 11.3). In patients where the femoral fracture was an isolated injury, the HRQoL-scores were consistently higher compared with patients who sustained additional injures. (4) Conclusions: Treating diaphyseal fractures in adolescents with an ALFN resulted in good radiographic outcomes in all our cases. HRQoL, as measured by the iHOT, PedsQL, and Pedi-IKDC, was good to excellent; but it was consistently inferior in patients with additional injuries. These results suggest that the ALFN is a good alternative when patients are not suitable for ESIN, and that the HRQoL of adolescents who were treated with an ALFN is mainly influenced by the presence of additional injures, and less by the fracture of the femur itself.

[Termination of Reimbursement of Arthroscopy in Osteoarthritis of the Knee: Is This Decision Based on Scientific Grounds?] / Ausschluss der Arthroskopie bei Gonarthrose aus dem GKV-Leistungskatolog: Beruht diese Entscheidung auf wissenschaftlichen Kriterien?

Background In Germany, arthroscopy of the knee used to be an accepted procedure in the treatment of osteoarthritis of the knee. However, as of April 1, 2016 reimbursement for this procedure has been discontinued. This was a decision of the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA). That decision was based on a report of the German Institute for Quality and Efficiency in Health Care (IQWiG). This report is essentially based on a few studies, three of which have been published in the renowned New England Journal of Medicine. According to the IQWiG, there is "no hint, indication or proof of a benefit of therapeutic arthroscopy" in osteoarthritis of the knee. Since this statement does not coincide with clinical observations commonly made by orthopaedic surgeons, the aim of this analysis was to evaluate the aforementioned studies according to criteria of evidence-based medicine. Material and Methods The three studies on which the IQWiG report is essentially based (Moseley et al. 2002, Kirkley et al. 2008 and Katz et al. 2013), all published in the New England Journal of Medicine, were analyzed according to the standards of evidence-based medicine. Results Although all of the evaluated studies were randomized controlled studies, there were considerable and serious deficiencies. These deficiencies include, among others, sampling bias that affects external validity and selection bias that affects internal validity. While a sham operation was performed in one study, resulting in an ideal blinding of study participants, that study used a non-validated primary outcome measure. That outcome score has not been used in subsequent publications and the algorithm presented for the calculation of the outcome score was incorrect. Although the other studies used validated main outcome measures, patients in those studies were not blinded. A number of further deficiencies were identified as well. Conclusion The studies on which the decision of the Joint Federal Committee is based do have several significant and at times severe methodological deficiencies. For instance, the results of these studies cannot be generalized to all patients suffering from osteoarthritis of the knee, solely on the basis of patient selection. Many of these deficiencies have not been mentioned till now, neither in the literature nor in the final report authored by the IQWiG. Therefore, it seems unlikely that the Joint Federal Committee was aware of these deficiencies when it decided to discontinue reimbursement for arthroscopy in patients with osteoarthritis of the knee. Unfortunately, not all patients suffering from osteoarthritis of the knee respond to conservative therapy. By discontinuing reimbursement for arthroscopy in this patient group, a commonly used treatment option has been withdrawn. The proportion of such patients was 30% after 6 months and 35% after 12 months in one of the studies considered by the IQWiG. It is hence conceivable that the indication for joint replacement surgery could become more generous after the withdrawal of arthroscopy as an alternative treatment option. In summary, it became clear that, given the variety and severity of the deficiencies of the underlying studies, the decision of the Joint Federal Committee could not have been based on scientific criteria. To this extent, it seems appropriate to revive the discussion about the exclusion of arthroscopy from the performance catalogue of the German Health Insurance System.