INTRODUCTION:Patients with clinical suspicion of hip fracture, but negative radiographs are suspected of having an occult hip fracture (OHF). Different diagnostic modalities are available for investigating OHF and various protocols have been suggested. MRI has the highest sensitivity and specificity, however availability is limited in many institutes. CT is readily accessible in the large majority of hospitals throughout the world but has lower sensitivity and may miss some fractures. In this article we investigate a protocol that balances these issues providing a practical and cost-effective solution. METHODS:During a four-year period between 2012 and 2016 a strict diagnostic protocol was followed at our Medical Center for patients suspected of OHF. This MRI selective protocol consisted of CT initially being performed and only when negative for fracture, followed by an MRI. Retrospective analysis of all patients who followed the protocol was performed. The patients were divided into two groups: those diagnosed by CT alone and those diagnosed by MRI after having a negative CT scan. Diagnostic performance, time to diagnosis and the cost of this protocol were evaluated. RESULTS:103 patients were treated under the protocol. In 50 patients (49%) hip fracture was diagnosed by CT alone. In the remaining 53 patients (51%) no definitive diagnosis was reached by CT and MRI was subsequently performed. 12 of these 53 patients (23%) were diagnosed with hip fracture necessitating surgery. In the CT only group mean time from admission to diagnosis was 3 hours, in the CT + MRI group this rose to 40 hours. Cost analysis showed that this protocol was more cost-effective than performing MRI in all patients, saving an estimated 66,805 Euro during the study period. CONCLUSION:The clinical challenge of diagnosing OHF can be minimised by implementing a diagnostic protocol. The protocol should take into consideration the diagnostic sensitivity, availability and cost of different imaging modalities. An MRI selective strategy with initial CT scanning is recommended, as it reduces time to diagnosis and lowers overall costs.

Bone involvement in Gaucher disease causes disability and reduced quality of life; loss of function and pain are important indications for enzyme replacement therapy. The purpose of this study was to ascertain whether osteoprotegerin (OPG), which decreases osteoclast activity, is indicative of incipient bone involvement by comparing OPG serum levels to Gaucher disease severity (SSI) and bone mineral density (BMD), and to correlate bone and disease markers to OPG polymorphisms: OPG1-2(A163G), OPG3-4(T129C) and OPG5-6(C1217T). Of 554 patients, 173 Ashkenazi Jewish patients with non-neuronopathic Gaucher disease were enrolled and 32 healthy Ashkenazi Jews served as controls. Serum OPG levels were detected by enzyme-linked immunosorbent assay and BMD was obtained by dual X-ray absorptiometry. OPG polymorphisms were determined in 63 randomly chosen patients. Serum OPG values for patients were not greater than in controls, but showed a statistically significant trend to increase with age (P = 0.057). No correlation existed between OPG levels and BMD or with genotype or other disease markers. A significant correlation was noted between OPG5-6 genotype and SSI. A significant difference was found between the allele distributions of each OPG polymorphism when compared with Caucasians and Ashkenazi Jews. OPG levels probably do not predict BMD in Gaucher disease and hence are not indicative of osteoporosis in Gaucher disease.

BACKGROUND:Pediatric femur fractures are common injuries necessitating immediate application of spica cast or surgical stabilization. Currently, neither conservative nor operative fixation shows superior results; nevertheless, operative intervention has become more common lately. The current study retrospectively investigates short term results of immediate spica cast application, as well as the economic consequences of this treatment.METHODS:All cases of pediatric (6 months - 6 years) femur fractures treated in a single medium-sized hospital during 3 years were reviewed. Characteristics of fracture treatment and economical aspects were analyzed.RESULTS:Twenty four patients (17 boys and 7 girls, mean age 2.5 years, range 9 months to 5.5 years), were treated during the study period by immediate closed reduction and spica cast application. Eleven patients were also treated for medical reasons. All cases achieved acceptable alignment and shortening after cast removal. Two patients were re-admitted to the hospital Emergency Room but no changes in treatment were needed, one patient needed re-reduction. Mean hospital stay was 2.75 days. Calculated cost of such treatment is estimated to be almost equal to the compensation given by insurance companies (based on hospital stay in Israel).CONCLUSIONS:Immediate application of spica cast for pediatric femur fractures, achieves its goals of appropriate fracture-alignment and acceptable complication rates. The authors believe that the compensation should be procedure-based and not hospital-stay based, in a way that will encourage higher efficacy of medical treatment and shortened hospital stay.

Gaucher disease, the most prevalent lysosomal storage disorder, is characterized by hepatosplenomegaly, hypersplenism, and rarely, neurological involvement. The most variable symptoms relate to skeletal disease, and both onset and progression are difficult to predict on the basis of genotype. This review describes findings from a large referral clinic (> 500 patients) and from the literature in the decade since the advent of specific enzyme replacement therapy. Such therapy is effective in reducing visceral and hematological involvement, but its greatest advantage as regards the skeleton is prevention of irreversible damage. Avascular necrosis of the joints-particularly the hips but also the knees and shoulders-and pathological fractures of the long bones including the ribs, as well as episodic "crises' of bone pain in children and young adults, are common manifestations. Various imaging modalities should be performed at baseline for life-long monitoring, and then as required because of specific complaints. Surgical interventions such as joint arthroplasties are important adjuvant treatments in this population; presurgical hematological profiling plus antibiotic cover and postoperative pain control are equally critical. Opportunities for orthopedic consultations with senior surgeons are not abused by our patients. These reflect disease-related morbidity, with greater numbers of requests being made by patients requiring enzyme therapy, who by definition have more severe disease characteristics.

Gaucher disease, the most prevalent lysosomal storage disorder, is caused by an inherited enzymatic defect with consequent accumulation of undegraded glucocerebroside in monocyte-macrophage cells, known as the "Gaucher cells" [1]. The most debilitating, albeit most variable symptom, is bone involvement: pathologic fractures after slight trauma, destruction of heads of the femur or humerus in the hip or shoulder joints (avascular necrosis), and compression fractures of the spine, as well as "bone crises" of pain, which although self-limiting and diminishing after puberty may require pain relief. It was hoped that the introduction of enzyme replacement therapy for Gaucher disease [2] would eliminate this devastating involvement of bones. We present the case of a patient with an osteolytic lesion of the proximal tibia that developed under enzyme therapy. The use of various imaging techniques for differential diagnosis is discussed.

This retrospective survey includes 29 total hip arthroplasties (THAs) in 23 patients with Gaucher disease, with heterogeneous techniques, with various prostheses, and performed by 9 different surgical teams. THA was discouraged in patients with Gaucher disease because of a tendency toward infection, poor bone matrix because of Gaucher cell infiltration, and deterioration of matrix with disease progression. Subjective assessment of pain and function, objective examination of outcome, and radiologic signs of loosening after THA were evaluated. In primary THAs, there was enhancement of quality of life, allowing restoration of full participation in normal activities; function was improved; radiologic evidence of loosening was low; and there were no infections. In revisions, the results were not as good. THA is recommended in this population using criteria comparable to those in other patients, with equally good results.

Syme ankle disarticulation for foot infections in diabetics with concomitant peripheral vascular disease is often unsuccessful. The need for re-amputation usually results from recurrent infection or ischemia of the posterior heel flap. We present 5 such cases of deep foot infections in diabetics who underwent Syme amputation after failure of local debridement. All patients needed reamputation in 4-18 days for ischemia of the flap.

Fracture of the patella is not uncommon after direct anterior knee trauma. However, there are other medical situations that resemble it radiologically. We present a patient mistakenly diagnosed as having a patellar fracture who had primary, solitary, malignant B-cell lymphoma of the knee space eroding the lower pole of the patella. We have found no reports of such a lesion in the literature. Another common benign condition that might erode adjacent bone is chronic synovitis. Our patient was treated with chemo- and radiotherapy and the lesion fully regressed with no evidence of local or systemic recurrence 1.5 years after diagnosis.