A global call to action to improve the care of people with fragility fractures.

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity. Initiated by the Fragility Fracture Network (FFN) at a "Presidents' Roundtable" during the 5th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay. There is an urgent need to improve: To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.

EULAR/EFORT recommendations for management of patients older than 50†years with a fragility fracture and prevention of subsequent fractures.

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

[Rehabilitation concepts and return to sport after interventions on the shoulder]. / Rehabilitative Konzepte und Rückkehr zum Sport nach Eingriffen an der Schulter.

BACKGROUND: Rehabilitation of athletes following surgical interventions for shoulder injuries is of utmost importance for recovery and return to sport. OBJECTIVES: The aim was to determine adequate concepts for rehabilitation following shoulder surgery in athletes. METHODS: A selective literature search was carried out in PubMed and a review of the available concepts is given taking personal experiences as well as national and international recommendations into consideration. RESULTS: This article presents the basic principles of functional rehabilitation, the kinetic chain and the different phases in rehabilitation. Specific rehabilitation concepts and return to sport strategies following traumatic dislocation, superior labrum anterior to posterior (SLAP) lesions and rotator cuff tears are presented. There is little high-level scientific evidence available for the treatment of these patients and most concepts are based on clinical experience and expert opinion. CONCLUSION: Rehabilitation of athletes with shoulder injuries requires a broad consensus strategy with respect to the next steps. Individual concepts for rehabilitation should take surgical and patient-specific criteria into consideration. Further research is urgently required to develop evidence-based recommendations.

[Undergraduate education in orthopaedic and trauma surgery - a nationwide survey in Germany]. / Die studentische Lehre im gemeinsamen Fach Orthopädie-Unfallchirurgie - eine deutschlandweite Statuserhebung.

AIM: Musculoskeletal conditions consume enormous resources and costs, and their incidence is increasing worldwide. Therefore, an appropriate education of medical students about these conditions is required. This study examines the extent of medical education in orthopaedic and trauma surgery in Germany. MATERIAL AND METHODS: A questionnaire comprising 7 topics (curriculum design, lecture, practical training, e-learning, examination, evaluation, resources) with a total of 44 items was sent to all assistant lecturers in orthopaedic and trauma surgery at the 37 medical schools in Germany. RESULTS: The survey attained a return rate of 76 % for orthopaedic surgery and 81 % for trauma surgery, respectively. Medical training in musculoskeletal conditions represents with an average of 38.4 hours of lectures and further 55.9 hours of practical training less than 6 % of the entire undergraduate medical education. This study demonstrates a high inhomogeneity regarding the curriculum design when comparing the different German medical schools not only in total training time but also regarding its contents. E-learning as additional teaching method is only offered in 39 % of orthopaedic training and in 47 % of the trauma surgery training. Practical examinations like the OSCE are offered at 8 medical schools for orthopaedic training and 15 schools for trauma surgical training, respectively. CONCLUSION: Medical training in musculoskeletal conditions is very inhomogeneous and requires further improvement and standardisation regarding quantity and implementation.

[Outcome assessment in geriatric trauma]. / Outcomes bei Alterstrauma.

The number of elderly and old patients with fractures is steadily increasing. Identification of relevant functional deficits and comorbidities is crucial for an efficient treatment strategy and outcome assessment in this patient group. For this reason the integration of a geriatric assessment in every orthopedic traumatology practice seems recommendable. Assessing the outcome of frequent fragility fractures (hip, radius) requires instruments oriented to the International Classification of Functioning, Disability and Health (ICF) which allow analysis of bodily function and structure as well as activity and participation. A combination of disease and body region-specific scores with generic scores seems to be reasonable. It can also be sensible to include instruments for health economic analyses.

[Using the international classification of functioning, disability and health (ICF) in trauma care]. / Anwendung der Internationalen Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) in der Traumatologie.

The International Classification of Functioning, Disability and Health (ICF) provides a comprehensive and structured treatment management and outcome evaluation in trauma care based on specific ICF core sets and the ICF-based Rehab-CYCLE. The Rehab-CYCLE allows the problem-based assessment of functioning in a multi-professional team under physician-guidance and the definition of long-term, intervention and cycle goals. Defined intervention goals are assigned to the appropriate intervention principles and techniques as well as the specific evaluation instruments. Together with the patient additional intervention goals are identified, intervention principals adapted and the further treatment setting planned based on a multi-professional outcome evaluation. The standardized documentation is reported multi-professionally on the ICF assessment sheet which reflects the patient perspective with all their problems and needs as well as the perspective of the treatment team.

[Introduction to the international classification of functioning, disability and health (ICF)]. / Einführung in die International Classification of Functioning, Disability and Health (ICF).

The WHO International Classification of Functioning, Disability and Health (ICF) allows a standardized description of functioning and disability based on individual and contextual factors. The ICF adopts a biopsychosocial model of disability and functioning and is complementary to the ICD-10 (International Classification of Diseases). For its implementation in clinical practice ICF-based instruments, such as the ICF core sets were developed in a standardized scientific process. These consist of the ICF categories which are most relevant for patients with specific diseases or in specific health care situations. In trauma care the ICF and ICF core sets can be applied in defined health problems and treatment situations for documentation of functioning, structured planning and implementation of interventions as well as outcome assessment.

[Development of a catalogue of undergraduate learning objectives for orthopaedics and traumatology]. / Entwicklung des Lernzielkatalogs "Muskuloskelettale Erkrankungen, Verletzungen und traumatische Notfälle" für Orthopädie-Unfallchirurgie im Medizinstudium.

BACKGROUND: The development towards a combined speciality of orthopaedic and trauma surgery requires not only consolidation and revision of the postgraduate education training programme but also the development of a catalogue of learning objectives as a uniform basis for undergraduate medical training in the new speciality at German medical schools and teaching hospitals. MATERIALS AND METHODS: Based on the Frankfurt catalogue of learning objectives for trauma surgery and the Ulm catalogue of learning objectives for orthopaedics, a task force of experts developed a combined catalogue of learning objectives for the new speciality. Experts from both specialities classified the learning objectives into two levels of knowledge and four grades of skills competence, in addition to objectives for attitudes and social competence. RESULTS: The section on general operative specialities contains 120 items classified into 39 learning objectives for knowledge and 83 for skills. Two learning objectives comprise both knowledge and skills. The section on orthopaedic and trauma surgery comprises 141 learning objectives, including six items for skills and 138 for knowledge, as well as three learning objectives for both knowledge and skills. In addition, 22 learning objectives deal with aspects of attitude and social competence. CONCLUSION: Although this alliance of orthopaedics and trauma surgery is recent, the commission has developed not only a collection of topics but a joint catalogue of learning objectives for undergraduate training that can be used nationwide. This catalogue paves the way for modern education that looks to the future. The integrated recommendations for content prioritisation, links to other subjects and specialities, and the integration of didactic methods facilitate local implementation of the learning objectives without loss of academic freedom.

[Development of a catalogue of undergraduate learning objectives for orthopaedics and traumatology]. / Entwicklung des Lernzielkatalogs "Muskuloskeletale Erkrankungen, Verletzungen und traumatische Notfälle" für Orthopädie--Unfallchirurgie im Medizinstudium.

BACKGROUND: The developments towards a combined specialty of orthopaedic and trauma surgery requires not only the consolidation and revision of the postgraduate education training programme but also the development of a catalogue of learning objectives as a uniform basis for undergraduate medical training in the new specialty at German medical schools and teaching hospitals. MATERIALS AND METHODS: Based on the Frankfurt Catalogue of Learning Objectives for Trauma Surgery and the Ulm Catalogue of Learning Objectives for Orthopaedics, a task force of experts has developed a combined catalogue of learning objectives for the new specialty. The experts of both specialties classified the learning objectives into 2 levels for knowledge, into 4 grades of competence for skills, as well as attitudes and social competence. RESULTS: The general part of the operative specialties contains 120 items classified into 39 learning objectives for knowledge and 83 for skills. Two learning objectives comprise both knowledge and skill. The part orthopaedic and trauma surgery comprises 141 learning objectives, six items for skills, 138 for knowledge, as well as three learning objectives for both knowledge and skills. In addition, 22 learning objectives deal with aspects of attitudes and social competence. CONCLUSION: In spite of the only recent alliance of orthopaedics and trauma surgery, the commission has developed not only a collection of topics, but also a usable joint catalogue of learning objectives for undergraduate training with a nationwide recommendation character. The catalogue paves the way for a forward-looking, modern education. The integrated recommendations for the prioritisation, the linkage to other subjects and specialties, and the integration of didactic methods facilitate the local implementation of the learning objectives without loosing any academic freedom.

Towards an ICF Core Set for chronic musculoskeletal conditions: commonalities across ICF Core Sets for osteoarthritis, rheumatoid arthritis, osteoporosis, low back pain and chronic widespread pain.

The objective of the study was to identify commonalities among the International Classification of Functioning, Disability and Health (ICF) Core Sets of osteoarthritis (OA), osteoporosis (OP), low back pain (LBP), rheumatoid arthritis (RA) and chronic widespread pain (CWP). The aim is to identify relevant categories for the development of a tentative ICF Core Set for musculoskeletal and pain conditions. The ICF categories common to the five musculoskeletal and pain conditions in the Brief and Comprehensive ICF Core Sets were identified in three steps. In a first step, the commonalities across the Brief and Comprehensive ICF Core Sets for these conditions were examined. In a second and third step, we analysed the increase in commonalities when iteratively excluding one or two of the five conditions. In the first step, 29 common categories out of the total number of 120 categories were identified across the Comprehensive ICF Core Sets of all musculoskeletal and pain conditions, primarily in the component activities and participation. In the second and third step, we found that the exclusion of CWP across the Comprehensive ICF Core Sets increased the commonalities of the remaining four musculoskeletal conditions in a maximum of ten additional categories. The Brief ICF Core Sets of all musculoskeletal and pain conditions contain four common categories out of a total number of 62 categories. The iterative exclusion of a singular condition did not significantly increase the commonalities in the remaining. Based on our analysis, it seems possible to develop a tentative Comprehensive ICF Core Set across a number of musculoskeletal conditions including LBP, OA, OP and RA. However, the profile of functioning in people with CWP differs considerably and should not be further considered for a common ICF Core Set.

[Socioeconomic relevance of osteoarthritis in Germany]. / Sozialmedizinische Bedeutung der Arthrose in Deutschland.

AIM OF STUDY: The aim of this study was to summarise the impact of medical care and related costs due to the treatment of osteoarthritis in Germany. MATERIAL AND METHODS: Data from different health care institutions, government authorities and public health insurances for the year 2002 were analysed. Amount and cost of acute and rehabilitation treatments (in-patient as well as out-patient), sickness leave and early retirement related to osteoarthritis were estimated. RESULTS: Advanced hip and knee osteoarthritis have a high socioeconomic impact in Germany. The number of people affected is growing, as is the overall incidence of joint replacement, especially knee arthroplasties and the percentage of in-patient rehabilitation for osteoarthritis. CONCLUSION: Our study confirms that the direct and indirect costs attributable to osteoarthritis are substantial and the resulting socioeconomic burden is significant. Since age is a major risk factor for osteoarthritis, the demographic changes will lead to an increased need for medical treatment of osteoarthritis patients in the future.

Gait analysis and WOMAC are complementary in assessing functional outcome in total hip replacement.

OBJECTIVE: To investigate the correlation between objective and subjective evaluation of patients with total hip replacement. DESIGN: Prospective preliminary trial comparing the Western Ontario and McMaster University questionnaire (WOMAC) and gait analysis preoperatively and three months postoperatively. SETTING: A German academic orthopaedic centre specializing in total hip replacement surgery. SUBJECTS: Seventeen patients (median age 70 years) with hip osteoarthritis. INTERVENTION: All patients had had a primary unilateral total hip replacement. MAIN MEASURES: WOMAC questionnaire to assess self-perceived health status and gait analysis to determine objective gait parameters. RESULTS: Performance of walking as well as subjective judgement of health status improved following surgery (gait speed P = 0.0222; stride length P = 0.038; stance phase ratio P = 0.0466; WOMAC P < 0.0001). However, the correlation between gait parameters and WOMAC was poor (r = -0.27 or less). Correlation between changes of walking parameters and WOMAC was bad to good (r = 0.01 to r = -0.72). CONCLUSION: The WOMAC questionnaire might not reflect walking performance. The addition of gait analysis is recommended to gain objective information about the quality of gait.

Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians.

OBJECTIVES: To analyse differences of opinions on indications for primary total hip replacements (THRs) within and between groups of orthopaedic surgeons and the physicians who refer patients to them. METHODS: 22 orthopaedic centres in 12 European countries took part, resulting in a postal survey of 304 orthopaedic surgeons and 314 referring physicians. Each participant was asked to state what importance different domains (pain, functional impairment, physical examination and radiographs) have on their decision to recommend THR and to select the most appropriate level of severity of each symptom or sign for recommending THR. In addition, the participants were asked to prioritise other personal or environmental factors that affect their decision to undertake a THR. RESULTS: Rest pain, pain with activity and functional limitations were the most important criteria for THR, although range of motion and radiographic changes were of least importance. Both similarities and differences were observed within and between groups of surgeons and referring physicians in the overall approach to indications and the most appropriate level of severity of disease for recommending THR. Most surgeons agreed on severity levels in only 4 of 11 items and most referring physicians in only one. Between the groups, major differences occurred with regard to the importance of activities of daily living and the appropriate level of symptoms for THR. In general, compared with surgeons, referring physicians reported that the disease needed to be more advanced to warrant surgery. CONCLUSION: Currently, no consensus exists on objective indication criteria for THR. The observed differences between the gatekeepers (referring physicians) and surgeons can lead to variations and perhaps inequities in the provision of care.

[Osteoporosis--a neglected issue in orthopaedics? Results of a survey amongst German orthopaedic surgeons]. / Osteoporose -- Ein Stiefkind der Orthopädie? Ergebnisse einer Befragung deutscher Orthopäden.

AIM: Patients with fragility fractures have a significantly increased risk of sustaining additional fractures. Therefore one should consider avoidance of further fractures as the primary treatment principle. Since orthopaedic surgeons manage most of fragility fractures, but might not be well attuned to osteoporosis itself, it was the aim of the Bone and Joint Decade (BJD) and the International Osteoporosis Foundation (IOF) to survey orthopaedic surgeons in order to assess their knowledge of prevention, diagnosis, and treatment of osteoporosis. MATERIAL AND METHODS: The multinational survey questionnaire was developed by a working group of national project co-ordinators in France, Germany, Italy, Spain, the United Kingdom, and New Zealand and based to some extent on an American survey. Following translation into the national language it was distributed in 2002 to the members of the orthopaedic societies to assess the management of prevention, diagnosis, and therapy of osteoporosis and fragility fractures, comparing both different health-care systems and different working environments. 5 700 questionnaires were distributed in Germany with a 20 percent response rate. RESULTS: As the main result of the German survey -- independent of the working environment -- a substantial deficit concerning training and knowledge about the management of prevention, diagnosis, and treatment of osteoporosis and fragility fractures was seen. In addition, the majority of participants requested educational opportunities to become qualified for a better disease control. CONCLUSION: In order to satisfy the increasing need for adequate management of prevention, diagnosis, and therapy of osteoporosis and fragility fractures, structured educational opportunities have to be offered to the German orthopaedic community. In the mean time first steps have been initiated: training courses to qualify as "Osteologe DVO" and the "White Book Osteoporosis", which was initiated by BJD and IOF and developed by several German medical societies and patient organisations it is based on the German DVO guidelines providing an evidence-based and structured overview concerning all relevant aspects of osteoporosis and fragility fractures.

[Inpatient health care utilization for musculoskeletal disorders and injuries: a forecast study for Germany up to 2010]. / Stationäre Inanspruchnahme bei muskuloskelettalen Erkrankungen und Verletzungen: Vorausberechnung für Deutschland bis zum Jahr 2010.

BACKGROUND: The study is part of the project "Orthopaedics 2010 -- evaluation of the demand for the orthopaedic work force in the year 2010", initiated by the professional association of orthopaedists (BVO). The aim is to estimate the prospective number of orthopaedists for the sufficient medical care of musculoskeletal disorders and injuries. METHODS: The main data source was the official statistics of discharge rates from 1994 to 1999 and the German population forecasts from 1994 to 2010 of the Federal Office of Statistics, Wiesbaden, Germany. An univariate forecasting analysis was done using the Granger and Newbold method. RESULTS: All diagnostic categories of musculoskeletal disorders (arthropathies, dorsopathies, rheumatism, osteopathies) will increase up to four-fold from 1994 to 2010. Three of the four diagnostic categories of injuries (dislocations, sprains and strains; contusion; injuries and open wounds) will decrease by up to 15 percent, the diagnostic category of fractures will increase (10 percent). The stratified analyses by gender and age reveal that women and persons over 65 years old are more often affected by musculoskeletal disorders and injuries. CONCLUSIONS: Both demographic changes and changes in the utilization of inpatient care will lead to a substantial increase of hospital cases up to 2010. The presented results should be looked at together with their confidence limits as interval estimations. In addition, there are independent external factors such as the new prospective payment system (G-DRGs) that will influence the hospital admission rates as well.

[Femur head dislocation fractures. Long-term outcome of conservative and surgical therapy]. / Femurkopfluxationsfrakturen. Langzeitergebnisse der konservativen und operativen Therapie.

From 1974 to 1989, we treated 32 patients with a femoral head fracture: 28 were associated with a traumatic posterosuperior dislocation of the hip (6 Pipkin type I, 7 type II, 4 type III and 11 type IV), 1 with a posteroinferior and 3 with an anterior displacement of the femoral head. Twenty-four patients had been involved in a traffic accident, 23 had associated injuries, and the average polytrauma score (PTS) was 21. All dislocations primarily treated at our hospital were reduced by closed methods within 4 h (mean 105 min). Eleven patients received no further operative treatment, 21 were treated by open reduction and screw fixation of the fragment of the head (n = 7), fixation of the acetabular fracture (n = 3) or removal of the fragments of the head (n = 10). Four Pipkin type III fractures received primary total hip replacement. Twenty-six of the surviving 29 patients were reviewed after an average follow-up of 5 years (2-11). Radiological signs of mild arthrosis were seen in 4, moderate degeneration in 2. Partial avascular necrosis was found in 4, subchondral collapse in 1 and heterotopic ossification in 8 patients. According to the Thompson and Epstein criteria 15 of 26 patients presented fair to poor results.

[Isolated hip dislocation of traumatic origin]. / Isolierte Hüftluxationen traumatischer Genese.

The final outcome following isolated traumatic dislocation of the hip that is reduced within 6 h is generally believed to be excellent. Forty-nine patients with an isolated dislocation of the hip were treated between 1974 and 1989 at the Department of Traumatology of the Hannover Medical School. The majority of patients were involved in traffic accidents, and 42 had associated injuries. All dislocations primarily treated at our hospital were reduced by closed methods within 3 h, (average 85 min, range 10-180 min), followed by early mobilisation with partial weight-bearing for 2-3 weeks. 42 patients were evaluated after an average follow-up period of 7.7 years. Radiological signs of partial necrosis were seen in two patients. Mild arthrosis was found in seven patients, moderate degeneration in two and heterotopic ossifications in four patients (two Brooker II, one Brooker III, one hip ankylosed). Twenty-nine of 33 MRI examinations were normal. Despite early reduction only 9/12 anterior and 14/30 posterior dislocations revealed excellent and good results according to the Thompson and Epstein classification. According to the present study the important prognostic factors are the direction of dislocation, the overall injury severity and the age at the time of injury.