[Routine Practice Data for Health Care Analyses: Part 3 of the Manual]

Analyses of health and health care (hereafter referred to as "health care analyses") usually aim to make transparent the structures, processes, results and interrelationships of health care and to record the degree to which health care systems and their actors have achieved their goals. Health care-related data are an indispensable source of data for many health care analyses. A prerequisite for the examination of a degree of goal achievement is first of all an agreement on those goals that are to be achieved by the system and its substructures, as well as the identification of the determinants of the achievement of the objectives. Primarily it must be examined how safely, effectively and patient-centred systems, facilities and service providers are operating. It also addresses issues of need, accessibility, utilisation, timeliness, appropriateness, patient safety, coordination, continuity, and health economic efficiency and equity of health care. The results of health care include system services (outputs), on the one hand, and results (outcomes), on the other, whereby the results (patient-reported outcomes) and experiences (patient-reported experiences) reported are of particular importance. Health care analyses answer basic questions of health care research: who does what, when, how, why and with which resources and effects in routine health care. Health care analyses thus provide the necessary findings and key figures to further develop health care in order to improve the quality of health care. The applications range from capacity analyses to following innovations up to the concept of regional and supra-regional monitoring of the quality of care given to the population. Given the progress of digitalisation in Health Care, direct data from the care processes will be increasingly available for health care research. This can support care givers significantly if the findings of the studies are applied precisely and correctly within an adequate methodological frame. This can lead to measurable improved health care quality for patients. Data from the process of health care provision have a high potential. Their use needs the same scientific scrutiny as in all other scientific studies.

[Necessity and Ways to Develop Care Goals for the Health System in Germany - a Position Paper of the DNVF]

Gesundheits- und Versorgungsziele sind eine unverzichtbare Grundvoraussetzung für ein funktionierendes Gesundheitssystem. Das Dilemma des deutschen Gesundheitssystems ist, dass es nicht planvoll weiter entwickelt wurde, sondern dass es historisch gewachsen ist. In den letzten Jahren hat es sich im freien Spiel der Kräfte zu dem entwickelt, was es heute ist. Den aktuellen Zustand beschreibt die OECD so: Die Kosten des deutschen Gesundheitssystems entsprechen nicht den oft nur durchschnittlichen Gesundheitsergebnissen für die Bevölkerung. Zur Erfüllung der gesetzlichen Anforderungen (vor allem SGB V §§ 12, 27 und 70) braucht die Gesundheitsversorgung/das Gesundheitssystem in Deutschland konkrete Ziele. Eine Orientierung an Versorgungszielen zieht Maßnahmen auf allen Ebenen der Versorgung nach sich: auf der Makroebene (Gesamtsystem/gesamte Bevölkerung), auf der Mesoebene (unterteilt nach Regionen, spezifischen Bevölkerungsgruppen etc.) sowie auf der Mikroebene ( Patient:innen und Leistungserbringer) Ausgehend von nationalen und internationalen Erfahrungen zeigt das vorliegende Positionspapier des DNVF e.V. (Deutsches Netzwerk Versorgungsforschung) das Potenzial, wie operationalisierte Versorgungsziele eine effektive, finanzierbare und qualitativ hochwertige Gesundheitsversorgung gewährleisten können. Der Koalitionsvertrag der Ampelregierung propagiert eine Neuausrichtung mit Patient:innen bezogenen Versorgungszielen. Jetzt gilt es, aus dieser Absichtserklärung konkrete und umsetzbare Ziele abzuleiten und dabei alle wesentlichen Gruppen zu beteiligen. Ergänzend werden in diesem Prozess Werte und ethische Normen für die Umsetzung vereinbart. Das BMG (Bundesministerium für Gesundheit) sollte den Prozess der gesellschaftlichen Willensbildung zur Definition von Nationalen Versorgungszielen ermöglichen und fördern. Dazu bedarf es einer klaren politischen Willensbildung. Als Ergebnis liegen am Ende des Prozesses die Nationalen Versorgungsziele vor, die zusammen mit evidenzbasierten Fakten sowie mit validen und belastbaren Daten in einem Handbuch „Nationale Versorgungsziele“ veröffentlicht und gepflegt werden. Die operative Verantwortung für die Umsetzung könnte bei dem neu zu gründenden Bundesinstitut für öffentliche Gesundheit liegen, wie es bereits im Koalitionsvertrag der Ampelkoalition angekündigt wurde. Das DNVF ist bereit, an der Entwicklung von Versorgungszielen aktiv mitzuwirken.

Health systems strengthening to arrest the global disability burden: empirical development of prioritised components for a global strategy for improving musculoskeletal health

INTRODUCTION

Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.

METHODS

Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.

RESULTS

Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening.

CONCLUSION

An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

Quality Improvement Initiatives in Fragility Fracture Care and Prevention

PURPOSE OF REVIEW

This review sought to describe quality improvement initiatives in fragility fracture care and prevention.

RECENT FINDINGS

A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

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.

[Medical rehabilitation from a lifespan perspective]

Lifespan research investigates the development of individuals over the course of life. As medical rehabilitation deals with primary and secondary prophylaxis, treatment, and compensation of chronic illnesses, a lifespan perspective is needed for the classification and diagnosis of chronic disorders, the assessment of course modifying factors, the identification of vulnerable life periods and critical incidents, the implementation of preventive measures, the development of methods for the evaluation of prior treatments, the selection and prioritization of interventions, including specialized inpatient rehabilitation, the coordination of therapies and therapists, and for evaluations in social and forensic medicine. Due to the variety of individual risk constellations, illness courses and treatment situations across the lifespan, personalized medicine is especially important in the context of medical rehabilitation, which takes into consideration hindering and fostering factors alike.

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.

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.

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.

Patient preoperative expectations of total hip replacement in European orthopedic centers

OBJECTIVE

Patient expectations have been identified as a factor that may account for individual differences in recovery after total hip replacement (THR) surgery. However, patient expectations have not been studied within a valid theoretical framework. This study employed the World Health Organization's model of health, the International Classification of Functioning, Disability and Health (ICF), to classify the content of preoperative patient expectations of THR.

METHODS

A European cohort of 1,108 patients preoperatively reported 2 types of expectations. Patients reported what they anticipated surgery would enable them to do that they needed to be able to do ("need" expectation), and what they would like to be able to do ("desire" expectation) in a year's time. Free-text responses were independently classified by 2 researchers to 1 or more of the ICF constructs of impairment, activity limitation, and participation restriction.

RESULTS

Interrater reliability was high (κ = ≥0.87). All patient expectations were classified to the ICF constructs. Less than 5% of patient expectations were identified as impairment, 58% of "need" expectations were identified as activity limitations, and 45% of "desire" expectations were identified as activity limitations and participation restrictions combined.

CONCLUSION

The ICF is a suitable theoretical framework to study patient expectations of THR. THR targets impairment; however, few patient expectations were classified to the ICF definition of impairment. The majority of patient expectations were classified as activity limitation or a combination of activity limitation and participation restriction. Therefore, patient expectations of surgery focus on recovering valued activities rather than reversal of bodily impairments.

[Outcome assessment in geriatric trauma]

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.

[Development of a catalogue of undergraduate learning objectives for orthopaedics and traumatology]

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]

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.

Strategies for prevention and management of musculoskeletal conditions. Lower limb pain

This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence.

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]

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]

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.

Multinational survey of osteoporotic fracture management

Osteoporosis is characterized by a decreased bone mass and an increased bone fragility and susceptibility to fracture. Patients with a fragility fracture at any site have an increased risk of sustaining future fractures. Orthopedic surgeons manage most of these fractures and are often the only physician seen by the patient. Mounting evidence that orthopedic surgeons are not well attuned to osteoporosis led the Bone and Joint Decade (BJD) and the International Osteoporosis Foundation (IOF) to survey 3,422 orthopedic surgeons in France, Germany, Italy, Spain, the United Kingdom, and New Zealand. The majority of the respondents in all countries had the opinion that the orthopedic surgeon should identify and initiate the assessment of osteoporosis in patients with fragility fractures. Heterogeneous practice pattern exist in different countries; however, identification and treatment of the osteoporotic patient seems to be insufficient in many areas: half of the orthopedic surgeons surveyed received little or no training in osteoporosis. Only approximately one in four orthopedic surgeons in France, the UK and New Zealand regarded themselves as knowledgeable about treatment modalities. Less than one-fifth of the orthopedic surgeons arranged for a surgically treated patient with a fragility fracture to have a bone mineral density (BMD) test. Twenty percent said that they never refer a patient after a fragility fracture for BMD. Only half of the orthopedic surgeons in southern Europe know about the importance of some external risk factors for hip fractures (cataracts, poor lighting, pathway obstacles, poor balance). In summary, this survey clearly indicates that many orthopedic surgeons still neglect to identify, assess and treat patients with fragility fractures for osteoporosis. More educational opportunities need to be offered to orthopedic surgeons through articles, web-based learning and educational seminars. Development of a simple clinical pathway from evidence-based guidelines is an important step to ensure that optimal care is provided for patients with fragility fractures.

Improved education in musculoskeletal conditions is necessary for all doctors

It is likely that everyone will, at some time, suffer from a problem related to the musculoskeletal system, ranging from a very common problem such as osteoarthritis or back pain to severely disabling limb trauma or rheumatoid arthritis. Many musculoskeletal problems are chronic conditions. The most common symptoms are pain and disability, with an impact not only on individuals' quality of life but also, importantly, on people's ability to earn a living and be independent. It has been estimated that one in four consultations in primary care is caused by problems of the musculoskeletal system and that these conditions may account for up to 60% of all disability pensions. In contrast, teaching at undergraduate and graduate levels--and the resulting competence and confidence of many doctors--do not reflect the impact of these conditions on individuals and society. Many medical students do not have any clinical training in assessing patients with bone and joint problems. Under the umbrella of the Bone and Joint Decade 2000-2010, experts from all parts of the world with an interest in teaching have developed recommendations for an undergraduate curriculum to improve the teaching of musculoskeletal conditions in medical schools. The goal for each medical school should be a course in musculoskeletal medicine concentrating on clinical assessment, common outpatient musculoskeletal problems and recognition of emergencies. Improving competency in the management of musculoskeletal problems within primary care settings through improved education is the next aim, but there are needs for improvement for all professionals and at all levels within the health care system.

DNA ploidy in soft tissue sarcoma: comparison of flow and image cytometry with clinical follow-up in 93 patients

In soft tissue sarcoma, the prognostic importance of DNA ploidy status is limited. One possible explanation may be technical; small non-diploid stemlines will be diluted in relation to the presence of normal diploid cells and may not be detected by flow cytometry (FCM). We assessed DNA ploidy status in 93 tumors with both FCM and image cytometry (ICM). ICM may permit the exclusion of non-relevant cells. The ability of the two methods to detect non-diploid stemlines was compared, as were the prognostic consequences. The patients (54 males) had a median age of 69 years. Surgical procedures were performed on all patients. None of the patients had received preoperative radiotherapy or chemotherapy. FCM and ICM were performed with standard methods. The prognostic value was assessed with univariate and multivariate analysis. In 82 of the 93 tumors, a concordant ploidy status by FCM and ICM was found. In 5 FCM type 1-2 tumors (diploid), the identification of non-diploid stemlines by ICM did not influence the metastatic rates. Increasing tumor size, histotype other than liposarcoma, increasing malignancy grade, tumor necrosis, and ICM non-diploidy were univariate prognostic factors for metastasis. In a multivariate analysis, only tumor size larger than 9 cm was a prognostic factor. In about 10% of the tumors, a discrepancy between FCM and ICM ploidy status was found, but we could not find a consistent prognostic consequence of this. Neither FCM nor ICM ploidy status was an independent prognostic factor.

[Femur head dislocation fractures. Long-term outcome of conservative and surgical therapy]

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]

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.

Giant-cell tumours with fracture at diagnosis. Curettage and acrylic cementing in ten cases

Between 1971 and 1991 we treated 98 patients with giant-cell tumours, 15 of whom presented with a pathological fracture. They were most common around the knee (12). Nine fractures were intra-articular. The tumours were treated by curettage and acrylic cementing (10), excision and endoprosthesis (1), excision and allograft (1), curettage and autologous graft (2) or by resection of the fibular head (1). Four patients had local recurrence, three of whom were cured by repeat curettage and cementing. Pathological fracture through a giant-cell tumour is not a contraindication to treatment by curettage and acrylic cementing.

Proliferating cell nuclear antigen (PCNA) in high-grade malignant fibrous histiocytoma: prognostic value in 48 patients

Grading based on histopathologic features is used to predict survival in soft-tissue sarcoma. However, variations in clinical behavior between tumors of the same grade motivate a search for additional factors that correlate with prognosis. Proliferating cell nuclear antigen (PCNA) is expressed in proliferating cells during the G1, S and G2-phases. To evaluate a prognostic implication of PCNA, the tumors of 48 patients with malignant fibrous histiocytomas (13 grade III, 35 grade IV) with a minimum follow-up of 2 years were immunohistochemically studied. We used PC10, a monoclonal antibody (MAb) directed against PCNA, which allows cell proliferation in formalin-fixed, paraffin-embedded tumor tissue to be evaluated. We applied a semiquantitative PCNA grading scheme to all stained nuclei of an entire slide. The 3-year metastasis-free survival rate was 0.87 for patients in grade A (low PLNA rate), and 0.14 for patients in grade C (high PLNA). Our findings show that immunohistochemical evaluation of cell kinetics in soft-tissue sarcomas by PCNA might be a useful adjunct to conventional tumor grading.

Soft tissue sarcoma should be treated at a tumor center. A comparison of quality of surgery in 375 patients

We analyzed the quality of surgery in a population-based series of 375 patients with primary soft tissue sarcoma of the extremity (n 329) and trunk wall (n 46). The quality was measured as the total number of operations performed for the primary tumor--biopsy, excision, reexcision--and the local recurrence rate. A comparison was made between patients referred to our tumor center before surgery (n 195), after surgery (n 102), and not referred for the primary tumor (n 78). The total number of operations for the primary tumor in patients not referred was 1.4 times higher, and in patients referred after surgery 1.7 times higher than in patients referred before surgery. The local recurrence rate in patients not referred was 2.4 times higher, and in patients referred after surgery 1.3 times higher than in patients referred before surgery. Our findings show that patients with soft tissue sarcoma should be treated at a tumor center, and that they should be referred before surgery.

Isolated traumatic dislocation of the hip. Long-term results in 50 patients

From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries.

Metastasis-free survival after local recurrence of soft-tissue sarcoma

We analysed metastasis-free survival after local recurrence in a population-based series of 432 patients treated for soft-tissue sarcoma of the extremities or trunk wall. Local recurrence was found in 124 patients; of these, 73 had no detectable metastases when the last local recurrence was diagnosed. No patient received chemotherapy for local recurrence. The 73 patients had a 5-year metastasis-free survival rate of 0.73 after the last local recurrence, compared with 0.47 in all 124 patients with local recurrence. The 5-year metastasis-free survival rate was 0.76 in the 308 patients who had never developed local recurrence, and 0.68 in the whole series. The selection of patients with local recurrence but no concurrent metastasis creates a subset of the population with a good prognosis; this makes it difficult to evaluate the effect of treatment for local recurrence on survival rate. In studies of prognosis this group of patients should be analysed separately from patients with primary tumours.