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.

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.

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.