Introduction: A hand and wrist disorder affects a patient’s overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers’ confidence in the choice and application of these outcome instruments. Methods: A literature search (1950–January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n = 341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist. Results: We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties. Conclusions: The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve. 2010 Elsevier Ltd. All rights reserved.

INTRODUCTION:A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers' confidence in the choice and application of these outcome instruments. METHODS:A literature search (1950-January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n=341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist. RESULTS:We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties. CONCLUSIONS:The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.

BACKGROUND:Metal-on-metal Birmingham hip resurfacing (MOM-BHR) is an alternative to metal-on-metal total hip arthroplasty (MOM-THA), especially for young and/or active patients. However, wear resulting in increased serum ion levels is a concern.QUESTIONS/PURPOSES:We asked whether (1) serum chromium (Cr), cobalt (Co), and molybdenum (Mo) concentrations would differ between patients with either MOM-BHR or MOM-THA at 5 years, (2) confounding factors such as gender would influence ion levels; and (3) ion levels would differ at 2 and 5 years for each implant type.PATIENTS AND METHODS:Ions were measured in two groups with either MOM-BHR (n = 20) or MOM-THA (n = 35) and a mean 5-year followup, and two groups with either MOM-BHR (n = 15) or MOM-THA (n = 25) and a mean 2-year followup. Forty-eight healthy blood donors were recruited for reference values.RESULTS:At 5 years, there were no differences in ion levels between patients with MOM-BHR or MOM-THA. Gender was a confounding factor, and in the MOM-BHR group at 5 years, Cr concentrations were greater in females compared with those of males. Mean ion levels were similar in patients with 2 and 5 years of followup for each implant type. Ion levels in patients were sevenfold to 10-fold higher than in controls.CONCLUSIONS:As the metal ion concentrations in the serum at 5 years were in the range reported in the literature, we do not believe concerns regarding excessive metal ion levels after MOM-BHR are justified.LEVEL OF EVIDENCE:Level III, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

Introduction Osteoporosis is a chronic and progressive condition that leads to decreased bone mass and skeletal fragility which may result in fractures, disability, pain, deformity and even death. Fractures of the wrist are the most common symptomatic fracture related to osteoporosis in which up to 80% of the persons with this fracture type have low bone mass. External fixation is minimally-invasive and is used in particular for the treatment of displaced, unstable fractures. Objective The present systematic review will present functional outcome assessment in randomized controlled trials in the aged with distal radius fractures and treated with external fixation. Materials and methods Multiple databases including Medline, EMBASE, CINAHL, AMED and OVID Healthstar were searched. MESH headings such as: “Radius fractures” or “wrist injuries” were used in combination with “randomized controlled trials”. Studies were included if the surgical treatment was external fixation, mean patient age was 50 years and over, and were in the English language. Results The primary focus of wrist outcome assessments in patients treated with external fixation were based on traditional measures such as wrist range of movement and grip strength reflecting the need to shift the focus in future protocols towards measuring a patient’s functional ability, measuring the difficulty of task performance and compensatory mechanisms. Furthermore, it is essential to take into account more evidence of instrument development before clinicians can reliably choose the best measure to assess the aged treated with external fixation.

This issue of the Journal of Orthopaedic Trauma gives an overview of 2 comprehensive workshops held in Bologna, Italy, and Rome, Italy, organized by the Osteoporotic Fracture Campaign*, an initiative of the International Society for Fracture Repair, endorsed by the International Osteoporosis Foundation. The workshops investigated the challenges faced not only by orthopaedic surgeons but also by engineers, radiologists, scientists, and rheumatologists in attempting to find the optimal treatment solution for elderly osteoporotic patients with distal radial fractures. These fractures pose a tremendous challenge to the orthopaedic community as osteoporotic patients have a high rate of unsatisfactory results due to the frequent inability of both conservative and surgical treatment to maintain fracture reduction for the time required for complete bone callus formation. As a consequence, fracture malunion and inadequate functional results are common. Given that the level of activity in the elderly is much higher in 2008 than in the past, it is necessary to assist them in retaining their quality of life. Indeed, action must be taken to improve the current results. These fractures also offer a tremendous opportunity to diagnose the osteoporotic disease. This can be effectively treated with a variety of pharmaceuticals thus reducing the risk of secondary fractures. In a panel discussion, topics ranged from accurate assessment of bone mineral density and issues concerning conservative fracture treatment, the use of fixation augmentation techniques such as hydroxyapatite-coated implants and calcium phosphate cements, and the types of fixation methods which yield the best results. Another issue of great importance is the preoperative use of dual energy x-ray absorptiometry as a tool not only to diagnose the osteoporotic disease but also to help in the selection of the most appropriate surgical treatment. Fracture signs that help to determine whether conservative or surgical treatment is appropriate were also addressed. If a fracture needing reduction is stable after the volar cortices are engaged, it will remain stable. In this case, conservative treatment can be considered. However, when there is comminution and significant displacement, surgical treatment is recommended. This should also be implemented in all patients who had received conservative treatment and in whom fractures redisplaced. Although less invasive fixation methods are still the most commonly used (workshop audience poll 75%), it was suggested that fixed-angle plate fixation implanted through the volar approach will become more popular than the traditional fixation methods, such as percutaneous pinning, external fixation, and plate fixation implanted through the dorsal approach. Advantages of fixed-angle plate fixation include the possibility to adequately expose the fracture site thus obtaining a better reduction. Another important advantage is faster rehabilitation. External fixation also plays a great role in this patient population. Such fixation can be augmented by using screws coated with hydroxyapatite, Kirshner wires, and calcium phosphate cements. It has been reported that although the popularity of fixed-angle plates is dramatically increasing, there is no evidence that it is superior to external fixation. Regardless of the chosen fixation method, the interface between the implant and the bone is of great importance. Implant stability can be improved by using screws coated

Total hip resurfacing has long been conceptually attractive to both surgeons and patients. However, historically it has been plagued by limited durability and marked acetabular bone loss. The recent development of wear-resistant bearings such as metal-on-metal has led to renewed interest in hip resurfacing in the orthopaedic community. We report the clinical and radiological results of 350 consecutive surface arthroplasties performed in 325 patients (mean follow-up 20 months). Harris Hip Score increased over time from 57 pre-operatively to 98 at 2 years follow-up. Complication’s rate was low. Four patients required revision surgery. The overall survival rate was 98.8%. Considering the positive results of more than 350 implants of our series, we now believe that there is evidence showing that this surgical concept deserves consideration, particularly when treating young patients with hip diseases.

Osteoporosis is defined as the deterioration of microarchitecture and overall poor bone quality, which represents a risk of implant fixation failure when patients with osteoporosis are surgically treated. Fragility fractures in elderly patients, typically at the hip, spine and wrist, should be assessed by the orthopaedic surgeon prior to surgery in order to select the most appropriate technique necessary to overcome failures and other complications associated with reduced osteofixation. In this review, advanced methods of augmenting implant fixation in osteoporotic bone are described including polymethylmethacrylate (PMMA), bone grafts, calcium phosphate implants, calcium phosphate cements, calcium phosphate coatings, modified implants and pharmaceutical augmentation concepts. The indication for these techniques should be based on the quantitative assessment of the osteoporotic quality of bone evaluated by dual energy X-ray absorptiometry (DXA).

External fixation has proven to be a viable minimally invasive treatment option for elderly patients with trochanteric fractures. Postoperative complications has limited external fixation in relation to inadequate pin fixation. We compared Orthofix pertrochanteric fixator (OPF) with hydroxyapatite-coated pins to dynamic hip screw (DHS) with AO/ASIF stainless-steel screws in osteoporotic trochanteric fractures. Methods: Forty patients were divided into two groups and randomized for treatment with 135° 4-hole DHS (Group A) or OPF with four hydroxyapatite-coated pins (Group B). Inclusion criteria was: female, age ≥ 65 years, AO fracture type A1 or A2 and BMD lower than -2.5 T-score. All fixators were removed at 3 months. Results: There were no differences in patient age, fracture type, BMD, ASA, hospital stay and reduction quality. Average number of blood transfusions was 2.0 ± 0.1 in Group A, whereas there were none in Group B (p < 0.0001). Operative time was 64 ± 6 minutes in Group A and 34 ± 5 in Group B (p < 0.005). Post-operative femoral neck shaft angle was 134 ± 6° in Group A, and 132 ± 4° in Group B (ns). In Group A, fracture varization at 6 months was 6 ± 8°, in Group B 2 ± 1° (p = 0.002). Harris hip score was 62 ± 20 in Group A and 63 ± 17 in Group B. (n.s.) In Group B, no pin infection occurred. Pin fixation was maintained over time, as shown by no significant difference between pin extraction and corresponding insertion torque. Discussion and Conclusion: In external fixation with hydroxyapatite-coated pins there was no need for blood transfusions and fixation was superior, as confirmed by less varization at long-term.

Moroni, Antonio MD; Faldini, Cesare MD; Pegreffi, Francesco MD; Hoang-Kim, Amy BSCH; Giannini, Sandro MD Author Information

The aim of this review is to report on studies of hydroxyapatite-coated external fixation pins as a solution to enhance pin fixation. In a highly loaded animal study, three tapered pin types were compared: Type A uncoated, Type B coated with hydroxyapatite and Type C coated with titanium. There was a 13-fold increase in the extraction torque of Type B pins compared with Type A, and a twofold increase compared with Type C pins. Extraction torque was significantly lower compared with the corresponding insertion torque in both Types A (p < 0.001) and C (p = 0.003). Conversely, with the hydroxyapatite-coated pins there was no difference between extraction and insertion torque. In a clinical study of 76 external fixation pins in 19 patients treated with hemicallotasis for osteoarthritis on the medial side of the knee, pin insertion and extraction torque forces were measured. The patients were randomized to be treated with either standard tapered pins or tapered pins coated with hydroxyapatite. Extraction torque of the hydroxyapatite-coated pins was higher than the extraction torque of the standard pins in both cancellous and cortical bone (p < 0.005). In a prospective, randomized clinical study of osteoporotic wrist fractures, extraction torque of the coated pins was higher than with standard pins (p < 0.0001). These studies demonstrate that with the use of hydroxyapatite-coated pins, no deterioration of pin fixation occurs, and that there is no significant pin loosening and infection, regardless of bone type and loading conditions.

Background: Although the use of a sliding hip screw is considered to be the preferred treatment for pertrochanteric femoral fractures, we theorized that external fixation could produce clinical outcomes equal to, if not better than, the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity and a reduced need for blood transfusions. Therefore, we compared the two treatments in a clinical trial of elderly patients with pertrochanteric fracture. Methods: Forty consecutive elderly female patients who had a pertrochanteric fracture were randomized to be treated with either fixation with a 135° four-hole sliding hip screw (Group A) or an external fixation device with hydroxyapatite-coated pins (Group B). The inclusion criteria were female gender, an age of at least sixty-five years, an AO/OTA type-A1 or A2 fracture, and a bone mineral density T-score of less than -2.5. There were no differences in patient age, fracture type, bone mineral density, comorbidities, length of hospital stay, or quality of reduction between the two groups. Results: The average intraoperative time (and standard deviation) was 64 ± 6 minutes in Group A and 34 ± 5 minutes in Group B (p < 0.005). The average number of units of blood transfused postoperatively was 2.0 ± 0.1 in Group A and none in Group B (p < 0.0001). Group B had less pain five days postoperatively (p < 0.05). Varus collapse of the fracture at six months averaged 6° ± 8° in Group A and 2° ± 1° in Group B (p < 0.002). No pin-track infections occurred in Group B. The average Harris hip score at six months was 62 ± 19 points in Group A and 63 ± 17 points in Group B. Conclusions: This study showed that external fixation with hydroxyapatite-coated pins is an effective treatment for this fracture in this patient population. The operative time is brief, the blood loss is minimal, the fixation is adequate, and the reduction is maintained over time. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Sliding hip screw fixation is the most common surgical treatment for pertrochanteric fractures. Intramedullary hip screw fixation is another popular surgical option; however, for either sliding hip screw or intramedullary hip screw fixation, mechanical complications such as lag screw cut-out are frequent. Furthermore with these fixation techniques, the inability to restore previous hip anatomy is common. Recently, external fixation has been proposed as a suitable fixation technique for pertrochanteric fractures. The main advantages of external fixation include: minimally invasive, short operative time, limited blood loss, and maintenance of the reduction obtained at surgery. For these reasons, we evaluated the results of pertrochanteric fractures treated with external fixation after a minimum follow-up of 6 months. Ten consecutive female osteoporotic patients (age ≥ 65 years) with AO/OTA fracture type A 1 or A 2 were included in the study. Fractures were treated with Orthofix pertrochanteric fixator (OPF) with four hydroxyapatite (HA)-coated pins. The mean patient age was 82 ± 7 years. The mean operative time was 34 ± 5 min. Fixators were removed three months postoperatively. There was union in all fractures. No blood transfusions were required postoperatively. There was no pin-track infection. The mean pin-insertion torque was 1 962 ± 1 215 N/mm and the mean pin extraction torque was 2 784 ± 1 648 N/mm. These latter results indicated improved pin fixation over time (p < 0.0005). There was no significant change in fracture reduction over time since there were no differences between the femoral-neck-shaft angle at 6 months and postoperatively. This study demonstrates that external fixation is a reliable treatment option for osteoporotic pertrochanteric fractures.

This study was done to determine if elderly patients with trochanteric fractures and with osteoporosis could benefit from treatment with a dynamic hip screw fixed with HA-coated AO/ASIF screws. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided into two groups and randomized to receive a 135°-four–hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws (Group A), or HA-coated lag and cortical AO/ASIF screws (Group B). Lag screw cutout occurred in four patients in Group A, but not in any patients in Group B. In Group A, the femoral neck shaft angle was 134° ± 5° postoperatively and 127° ± 12° at 6 months. In Group B, the femoral neck shaft angle was 134° ± 7° postoperatively and 133° ± 7° at 6 months. The Harris hip score at 6 months was 60 ± 25 in Group A and 71 ± 18 in Group B. The superior results of Group B can be attributed to the increased screw fixation provided by the HA-coated screws. We recommend lag screws coated with HA for dynamic hip screw fixation, especially in osteoporotic bone.

Aim: This study compared fracture treatment with plaster cast vs external fixation. Methods: Forty elderly female osteoporotic wrist fracture patients were randomized to be treated with either plaster cast (Group A) or external fixation (Group B). Bone mineral density less than −2.5 T-score was among the inclusion criteria. Results: In Group A, four redisplacements occurred, whereas in Group B there were none (p = 0.005). Horesh score was higher in Group B (p < 0.006) than in Group A. Volar angle deformity (p < 0.0005) and radial angle deformity (p = 0.008) were lower in Group B. Conclusions: This study shows that external fixation improves stability in elderly osteoporotic wrist fracture patients.

Dynamic Hip Screw (DHS) is. widely used to treat trochanteric fractures, although significant failure rates have been reported due to lag screw cut-out. This study was designed to compare treatment with DHS fixed with either standard or hydroxyapatite-coated lag and cortical screws in elderly osteoporotic trochanteric fracture patients. The incidence of fixation failure and the functional outcomes between the two groups Are reported herein.The incidence of lag screw cut-out in the standard group was similar to results seen in previous studies, but in the HA-coated screw group, no lag screw cut-out occurred. This can be attributed to the optimal osteointegration ability of the hydroxyapatite-coated screws and the resultant increased screw fixation. Hydroxyapatite-coated screws could resolve the problem of screw loosening in weak bone.

Elderly osteoporotic patients with pertrochanteric fractures are usually managed with DHS or Gamma Nails. Investigators have observed in these patients an higher intraoperative number of complications caused by a longer surgical time, and a consistent blood loss during surgery. External fixation represents a minimally invasive treatment option for elderly osteoporotic trochanteric fracture patients. This appealing method in osteoporotic bone is a challenge because of the potential for pin loosening and infection. Because of this, pins coated with hydroxyapatite are recommended in these cases.We wanted to determine whether or not similar improvement in fixation strength could be achieved in a highly loaded weight-bearing situation such as osteoporotic trochanteric fracture.

Bone response to hydroxyapatite coating on stainless steel has not been so extensively tested in animals as it happened for other metallic substrate, like Ti6Al4V. For this reason, authors performed an in vivo histomorphological electron microscopic study of hydroxyapatite coating on duplex stainless steel cylinders, to gather further evidences on the characters of bone apposition at the interface. Sixteen HA-coated cylinders were implanted in the distal femur of New Zealand White rabbits. Comparison with uncoated controls was made. Retrieval steps were at: 4, 8, 26 and 34 weeks. Specimens were analyzed in a Jeol JSM 6301F scanning electron microscope. The response to HA-coated samples has a morphological character of tight apposition between bone and coating. Osteocytic lacunae may be found few microns close to the coating and newly formed bone is extremely interlocked with it so that even an higher magnification electron-microscopy cannot resolve any discontinuity in between. Pictures of physiological bone-turnover are distinguishable at the bone-coating interface; areas of well preserved coating may be present together with areas where local exfoliation or fragmentation has already completely exposed the metallic substrate. On the opposite in uncoated samples, despite a morphological picture of properly formed bone, the largest area of the metal has no direct apposition with it.