Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA).

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Aims

The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Introduction

Many patients with displaced intracapsular femoral neck fractures (IFNF) are treated with hemiarthroplasty (HA) which has been shown superior to internal fixation(IF) the first year after injury. Long term results, however, are sparse.

Introduction: Tendinopathy entails pain and degenerative tissue proliferation such as tenocyte transformation and increased numbers of sensory nerves and microvessels. Pain and tissue proliferation are suggested to be modulated via nerve transmitters, including substance P (SP) and glutamate, both detected in tendinopathy. Substance P and glutamate are known to activate glutamate receptors in a variety of pain conditions and additionally to be implicated in cell transformation. However, the presence of different glutamate receptors, eg. ionotropic (NMDA) and metabotropic (mGlu), and whether they are up- or downregulated in tendinopathy is still unknown. In this study we assessed the

presence,

Methods: All procedures were conducted with local ethical committee approval and patient consent. Human patellar tendon biopsies of tendinopathic patients (n=10) and controls (n=8) were single- and double-stained immunohistochemically for glutamate, glutamate receptors NMDAR1, mGluR1, mGluR5 and mGluR6,7, the nerve marker PGP9.5 and SP and assessed subjectively and semi-quantitatively with image analysis. Images were taken using an epifluorescence microscope with camera and were subjectively assessed by two independent observers blinded with regard to the identity of the slides. Tenocyte density and morphologic characteristics were assessed. Non-parametric Mann-Whitney U-tests for independent samples were used, and the level for significance was set at p< 0.05.

Results: Of the glutamate receptors tested all except mGluR1 was identified in the tendons, however only NMDAR1 was found significantly altered between both groups. The chronic painful tendons exhibited a significant elevation of NMDAR1 (9-fold) and also of glutamate (10-fold). This up-regulation of NMDAR1 and glutamate was found to be co-localized on sensory nerve fibers, blood vessels as well as on transformed tenocytes. None of the controls exhibited neuronal co-existence of glutamate with NMDAR1.

Conclusions: This study establishes for the first time that patients with tendinopathy exhibit an elevation of peripheral glutamate receptor NMDAR1, morphologically co-localized with increased glutamate expression. The up-regulated NMDAR1/glutamate system may represent hyper-excitability of the cells – leading to cell proliferative effects observed as angiogenesis, tenocyte transformation, and nerve sprouting. Moreover, the neuronal co-existence of glutamate and NMDAR1 observed in painful tendinosis, but not seen in any of the controls, strongly suggests a role in pain signalling. Future studies will focuse on interventional approaches to investigate if modulation of NMDAR1 pathways can ameliorate the symptoms of tendinopathic patients.

The costs of hip fractures are high. For the individual suffering a hip fracture there are both physical and psychological costs. For society there are costs of medical attention such as hospital treatment, rehabilitation and an increased level of care. We aimed to assess whether total hospital and societal costs for the treatment of elderly patients with displaced femoral neck fractures differ between patients operated with either internal fixation or hemiarthroplasty.

Patients: 222 patients, 165 (74%) women, mean age 83 years, were randomized to either internal fixation or hemiarthroplasty and followed for 2 years. All patients, regardless of cognitive failure and poor function and health were included in the study. Patients underwent either a Charnley-Hastings bipolar cemented hemiarthro-plasty or closed reduction and internal fixation with two parallel cannulated screws (Olmed). Resource use in hospital, rehabilitation, community based care and nursing home use were prospectively included in the analysis.

Results: The average cost per patient for the initial hospital stay was significantly lower for patients in the internal fixation group compared to the hemiarthro-plasty group (€ 12,509 vs. € 16,923, p= 0.01). When all femoral neck fracture-related hospital costs, i.e. rehabilitation, re-operations and formal and informal contact with the hospital, were included, the cost was similar in two groups (€ 25,081 for internal fixation vs. € 26,828 for hemiarthroplasty, p= 0.52). Including all costs (all hospital admissions, cost of nursing home and community based care), there was a nonsignificant trend that internal fixation was the most expensive treatment, (€ 50,331 vs. € 42,615 (p=0.14)). Inpatient stay and nursing home use were the two must resource demanding items for both groups. Costs for re-operations was the area where the largest difference between the groups was found (€ 9,377 per patient for internal fixation vs. € 1,718 for hemiarthroplasty (p< 0.01).

Conclusion: The initial lower cost per patient for internal fixation as treatment of a femoral neck fracture cannot be used as an argument in favor of this treatment, since the difference in average cost per patient is more than outweighed by subsequent costs, mainly due to a higher re-operation rate after internal fixation than after hemiarthroplasty and a tendency to higher societal costs. The old orthopedic credo that internal fixation is the cheaper treatment, and thus should be preferred, could not be verified when other costs than the initial hospital stays were included.

Background: Alternative treatments in displaced fractures of the femoral neck include reduction and internal fixation, and arthroplasty. A variety of treatments are continuously introduced to the health care market and that makes prioritising, based on the severity of the disease, the effectiveness, and the cost effectiveness of the treatment, necessary. The aim of this study was to compare the estimated effect and costs of internal fixation and hemiarthroplasty after a displaced femoral neck fracture.

Methods: 222 patients, 165 (74%) women, mean age 83 years, were randomized to internal fixation (n = 112) and hemiarthroplasty (n = 110). Mainly due to cognitive failure or death, 56 patients failed to complete the EQ-5D questionnaire at any follow up; hence, 166 patients were included in the analysis. There were no differences in the demographic variables at inclusion. Patients underwent either a Charnley-Hastings bipolar cemented hemiarthroplasty or closed reduction and internal fixation with two parallel cannulated screws (Olmed). The health effect was estimated by the generic measure quality adjusted life-years (QALYs). The QALYs were estimated based on the patients’ perception of quality of life (QoL) assessed by Eq-5d, which was measured after 4, 12 and 24 months.

Results: Over the two year period the expected QALYs for patient with hemiarthroplasty and internal fixation were estimated to be 1.31 and 1.11, respectively. Thus, the incremental health effect, the difference in QALYs for hemiarthroplasty versus internal fixation, was 0.20 QALYs gained. Hospital costs over two years were € 30 726 in the internal fixation group and € 27 618 in the hemiarthroplasty group, an incremental cost of – € 3 108 in favor of hemiarthroplasty. Total costs, including societal costs, were € 62 815 in the internal fixation group, compared to € 48 227 in the hemiarthroplasty group, an incremental cost of – € 14 588 in favor of hemiarthroplasty. By dividing the incremental cost by the incremental effect, we found the incremental cost effectiveness ratio (ICER) to be – € 15 540 for all hospital costs and – € 72 940 for total costs. Sensitivity analysis based on the bootstrap method, indicate that the ICER is significantly negative, indicating both a significantly lower incremental costs and significantly higher QALYs for hemiarthroplasty versus internal fixation. Conclusion: Primary treatment with hemiarthroplasty generates more QALYs and is less costly compared to internal fixation. Hemiarthroplasty was thus the cost effective treatment alternative.