Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost?

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions.

Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: a randomised, prospective trial.

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.

Management of thrombocytopenia-absent radius (TAR) syndrome.

Thrombocytopenia-absent radius (TAR) syndrome is defined by bilateral absence of the radius and hypomegakaryocytic thrombocytopenia (<150,000/mm3). Lower extremity and nonorthopaedic anomalies also are frequently present. Charts and radiographs of 23 patients with TAR syndrome were reviewed, with extremity and other anomalies documented. Upper and lower extremity management, which included surgery and multiple attempts at orthotic and prosthetic fitting, was evaluated. Upper extremity prostheses were generally rejected, as most patients were able to perform tasks by approximating themselves closely enough to an object to use their own hands. Adaptive devices for feeding, dressing, and toileting were well tolerated. In the lower extremity, most affected patients either rejected any lower extremity intervention or had involvement that eventually precluded functional ambulation, necessitating power wheelchair or motorized cart use. The greatest degree of independence for these patients comes not from surgical, prosthetic, or orthotic intervention, but from the use of simple adaptive devices and powered mobility aids if required.

Evaluation of soft-tissue foreign bodies: comparing conventional plain film radiography, computed radiography printed on film, and computed radiography displayed on a computer workstation.

OBJECTIVE: The study was performed to evaluate detection of soft-tissue foreign bodies using conventional radiography (film-screen radiography), computed radiography printed on films (computed radiography-hard copy), and computed radiography displayed on a computer workstation (computed radiography-soft copy). SUBJECTS AND METHODS: Fifteen foreign bodies of different size, shape, and composition were implanted at different locations in a fresh cadaveric hand, and images were obtained using three radiographic techniques. Images were evaluated by four board-certified radiologists to ascertain the conspicuity of the foreign bodies with the different techniques. A subjective grade was assigned to each image in an attempt to identify the relative conspicuity of foreign bodies when imaged with the three techniques. RESULTS: Computed radiography-soft copy is the preferred imaging technique for the detection of wood and plastic foreign bodies in soft tissue regardless of the size of the wood or the plastic. No significant differences in conspicuity among the three techniques were demonstrated with glass foreign bodies. CONCLUSION: Detection of soft-tissue foreign bodies is best done using computed radiography-soft copy instead of film-screen radiography and computed radiography-hard copy imaging.

Correlation of creatine kinase and gait measurement in the postpolio population: a corrected version.

Measurements of stride length, gait speed, and distance walked during seven days were obtained from 15 postpolio and eight control subjects. Pedometers were used to measure distance walked. Measurements of stride length and speed were performed three times, and there was a high correlation between tests (R = .852-.969). The pedometers failed to record accurately in some postpolio subjects, and these subjects were dropped from analysis when ambulation distance was used as a variable. There were significant differences between the postpolio subjects and controls with respect to gait speed (47.7 +/- 14.0 vs 74.9 +/- 15.9 m/min, p less than 0.0005), stride length (55.3 +/- 11.7 vs 69.8 +/- 8.6 cm, p = .006), and average kilometers walked per day for seven days (1.97 +/- 1.3 vs 3.89 +/- 1.7, p = .016). The postpolio subjects had their serum creatine kinase (CK) levels measured at the end of the study. Forty percent of subjects had a level above the normal limits of our laboratory. There was a significantly positive correlation between CK levels and the distance walked during the previous 24 hours (R = .75, p = .012). The findings of this study illustrate the impact of gait abnormalities on the ambulatory abilities of the postpolio population. The correlation of CK with ambulation supports the association of exercise as a source of elevated CK levels in the postpolio population.

Correlation of creatine kinase and gait measurement in the postpolio population.

Measurements of stride length, gait speed, and distance walked during seven days were obtained from 15 postpolio and eight control subjects. Pedometers were used to measure distance walked. Measurements of stride length and speed were performed three times, and there was a high correlation between tests (R = .852-.969). The pedometers failed to record accurately in some postpolio subjects, and these subjects were dropped from analysis when ambulation distance was used as a variable. There were significant differences between the postpolio subjects and controls with respect to gait speed (47.7 +/- 14.0 vs 74.9 +/- 15.9m/min, p less than 0.0005), stride length (55.3 +/- 11.7 vs 69.8 +/- 8.6cm, p = .006), and average kilometers walked per day for seven days (1.97 +/- 1.3 vs 3.89 +/- 1.7, p = .016). The postpolio subjects had their serum creatine kinase (CK) levels measured at the end of the study. Forty percent of subjects had a level above the normal limits of our laboratory. There was a significantly positive correlation between CK levels and the distance walked during the previous 24 hours (R = .75, p = .012). The findings of this study illustrate the impact of gait abnormalities on the ambulatory abilities of the postpolio population. The correlation of CK with ambulation supports the association of exercise as a source of elevated CK levels in the postpolio population.