Background: A recent change in the Belgian law lead to the obligation of evaluating the musculoskeletal system among employees using visual display terminal (VDT) during the routine annual visit. We conducted a cross-sectional study to determine prevalence of and risk factors for musculoskeletal symptoms (MSS) and disorders (MSD) in general, and carpal tunnel syndrome (CTS) in particular.

Methods: During the routine annual visit all VDT employees of different kinds of companies and occupations were asked about upper extremity MSS by their occupational physician. Participants who met the criteria for MSS within the last month were physically examined in search of a MSD in general, and CTS in particular. Prevalences were calculated, and key risk factors for MSS and CTS were determined using logistic regression analyses.

Results: The total prevalence of any upper extremity MSS among 1087 VDT-employees was 31.3%. Neck symptoms (21.6%) were the most frequently reported, followed by shoulder (21.6%), elbow/forearms (4.1%), hands/wrists (7.3%), and finger (5.2%) symptoms. The prevalence of CTS depended on the diagnostic criteria used: 1.8% for symptom-specific CTS (typical anatomical distribution of numbness and paresthesias), 1.2% for examination-confirmed CTS (at least one positive provocative test, Tinel’s nerve percussion test or Phalen’s wrist flexion test), and 0.2% for electrophysiologically-confirmed CTS (abnormal nerve conduction tests). Logistic regression analyses identified increasing age, female gender, the duration of professional VDT use per day, a history of thyroid diseases, and a history of rheumatoid arthritis as significant and independent factors associated with MSS. Adaptation of the work-place was associated with a lower likelihood of MSS. Only increasing age and female gender were identified as significant and independent factors associated with CTS (symptom-specific and examination-confirmed CTS). Job-related factors were not significantly associated with an increased risk for CTS.

Conclusions: Our study confirms the high prevalence of MSS among Belgian visual display terminal users (more than 30%). Two work-related factors were clearly associated with MSS: the duration of professional VDT use per day (increased risk) and prior adaptation of the workplace according to advice given by the occupational physician (decreased risk). By contrast, the prevalence of CTS was low (less than 2%), and no job-related risk factors for CTS could be identified among VDT users.

Objectives: A recent meta-analysis (JAMA. 2005;293:2257–2264) reported that supplementation with oral vitamin D 700–800 IU/day reduces the risk of hip or any nonvertebral fracture in elderly individuals by approximately 25%. However, this metaanalysis was unable to define the role of additional calcium supplementation. The aim of the current study was to assess the need for calcium supplementation in individuals receiving vitamin D for the prevention of hip and nonvertebral fractures.

Methods: MEDLINE (search terms: ‘vitamin D’ AND ‘hip fracture’), bibliographies of articles retrieved, and the authors’ reference files were used to identify randomized controlled trials (RCTs) of oral vitamin D supplementation with or without calcium supplementation vs placebo/no treatment in postmenopausal women and/or older men (over 50 years) specifically reporting hip fracture risk. Data extraction was independent by

Results: All pooled analyses are based on random-effects models. Based on 4 RCTs (9083 subjects), the pooled relative risk (RR) of hip fracture for vitamin D supplementation alone was 1.10 (95% confidence intervals [CI], 0.89 to 1.36). No between-trial heterogeneity was observed. For the 5 RCTs (9227 subjects) of vitamin D supplementation with calcium supplementation, the pooled RR for hip fracture was 0.79 (95% CI, 0.64 to 0.97). There was no heterogeneity between trials. The RRs for all nonvertebral fracture were 0.98 (0.83 to 0.16) for vitamin D alone and 0.84 (0.73 to 0.96) for vitamin D with calcium, with moderate heterogeneity between trials. In an adjusted indirect comparison of the summary RRs from the 2 meta-analyses, the RR for hip fracture for vitamin D with calcium vs vitamin D alone was 0.72 (95% CI, 0.53 to 0.96) and the RR for all non-vertebral fractures was 0.77 (95% CI, 0.60 to 0.99).

Conclusions: Oral vitamin D supplementation appears to reduce the risk of hip and any nonvertebral fractures only when calcium supplementation is added. Our findings suggest that to optimize clinical efficacy, vitamin D supplementation should be complemented with calcium supplements.

Objectives: To determine the magnitude and duration of excess mortality after hip fracture among postmenopausal women.

Methods: We conducted a systematic review and meta-analysis of the literature to estimate the pooled relative risk of death after hip fracture by time since fracture. We selected only controlled studies that reported data on postmenaupausal women aged 50 years or older, carried out a life-table analysis, and displayed the survival curves of the hip-fracture group and an ageand sex-matched control group. Using random-effects models we calculated the pooled relative risk of death with 95% confidence intervals (95%CI) by time since fracture.

Results: Twenty-three studies contributed to this meta-analysis. The pooled relative risk of dying within three, six, twelve, and twenty-four months following hip fracture was 5.06 (95%CI: 4.31, 5.93), 3.92 (95%CI: 3.11, 4.94), 2.71 (95%CI: 2.33, 3.14), and 2.02 (95%CI: 1.83, 2.23), respectively. Thereafter, excess mortality remained relatively constant. The relative risk of mortality at five years, ten years, and fifteen years post-fracture was 1.44 (95%CI: 1.29, 1.62), 1.40 (95%CI: 1.35, 1.45), and 1.36 (95%CI, 1.31, 1.41), respectively.

Conclusions: Excess mortality among postmenopausal women having suffered a hip fracture was most apparent immediately after the event, declined steeply during the first years post-fracture, but did not return to that of age- and sex-matched controls, even at the longest duration of follow-up. The impact of a hip fracture on excess mortality among postmenopausal women continued for up to 15 years.

Purpose: We conducted a prospective study among elderly women with a first hip fracture to document survival and functional outcome, and to determine whether outcomes differ by fracture type.

Methods: The design was a one-year prospective cohort study in the context of standard day-to-day clinical practice. The main outcome measures were survival and functional outcome, both at hospital discharge and one year later. Functional outcome was assessed using the Rapid Disability Rating Scale version-2.

Results: Of the 170 women originally enrolled, 86 (51%) had an intertrochanteric and 84 (49%) a femoral neck fracture. There were no significant differences between the two groups with respect to median age (80 and 78 years, respectively), type and number of comorbidities, and prefracture residence at the time of injury. At hospital discharge, intertrochanteric hip-fracture patients had a higher mortality (relative risk [RR] 9.8; 95% confidence interval [CI]: 1.3 to 74.6; p=0.006) and were functionally more impaired (0.4 units difference in ability to walk independently; p=0.005). One year later, mortality was still significantly higher after intertrochanteric fracture (RR 2.5; 95% CI: 1.3 to 5.1; p=0.008), but functional outcome among surviving patients was similar in both groups. During the one-year period after hospital discharge, a significant functional recovery was observed regardless of fracture type (improvement by 3.9 units [p=0.003] and by 2.6 units [p=0.015] in patients with intertrochanteric and femoral neck fractures, respectively). In both groups, this recovery was reflected in a significant improvement in walking ability (p< 0.001 and p=0.006, respectively) and mobility (p=0.004 and p< 0.001, respectively).

Conclusions: We conclude that intertrochanteric fractures are associated with increased mortality compared to femoral neck fractures. Functional outcome differs according to fracture type at hospital discharge, but these differences do not persist over time. Our data provide evidence that these findings cannot be explained by differences in age or comorbidity. Differences in survival suggest that the two main types of hip fractures should be analyzed separately in clinical and epidemiological studies.

Introduction: Now that evidence base medicine gains importance scientifically good evaluation of the results of treatment is fundamental. There exist however a large number of evaluation tools for dorsolumbar disorders. These tools measure different aspects of outcome, like pain, impairment, handicap, disability, satisfaction and health perception. These tools are not always well validated either. These problems make it difficult to select the appropriate test for different purposes.

Aim of the study: To compose and evaluate a system of outcome measuring tools that covers most aspects of outcome and that is relevant to spine surgeons.

Materials and Methods: The tests were selected from literature, based on their scientific validity, their relevance, the frequency of their use by others and the ease of their use. The visual analogue scale for pain (VAS-pain), the low back outcome score (LBOS), the handicap subsection of the LBOS, the finger-tip to floor test (FTFT), The Oswestry disability index (ODI) and patient satisfaction were tested in a group of “pure-dorsolumbar-disorder-patients” (selected from a trauma group) and in a group of patients with degenerative disorders, as encountered in a spine surgery practice. The prospectively gathered pre- vs. postop. differences obtained with the different tests were compared with those obtained with the Oswestry disability index, which was chosen as “golden standard”. The obtained correlations (Kendall’s rank correlation coefficients and point-biserial coefficient) are a measure for the construct-validity and responsiveness of the different tests.

Results: The correlation with the ODI was: weak and not significant for VAS-pain in the degenerative group, for FTFT-distance in both groups, for FTFT-pain in the trauma group and for satisfaction in both groups. The same correlation was weak but significant for the VAS-pain in the trauma group and for the LBOS-handicap part in the trauma group. It was moderate for LBOS and the LBOS-disability part in both groups, for the LBOS-handicap part in the degenerative group and for FTFT-pain in the degenerative group. There was no correlation of satisfaction with the other tests. Correlation of FTF- pain with VAS-pain was not significant in the degenerative group and moderate and in the trauma group.

Aims: To explore potential predictors of functional outcome one year after the injury in elderly women who sustained a displaced intracapsular hip fracture and who were treated with internal fixation, hemiarthroplasty, or total hip arthroplasty.

Methods: Eighty-four women aged > 50 years were enrolled on a consecutive basis in this one-year prospective cohort study reflecting standard day-to-day clinical practice. The main outcome measure was the Rapid Disability Rating Scale version-2 applied at hospital discharge and one year later.

Results: The total hip arthroplasty group was younger (p< 0.001) and had a better functional status than the internal fixation or hemiarthroplasty groups (p< 0.001) at hospital discharge. One year later, the best function was still observed in the total arthroplasty group, but the differences were small and failed to achieve the level of statistical significance. During that one-year period, walking ability or mobility did not change significantly after total hip arthroplasty, but a significant proportion of the women developed cognitive impairment, including mental confusion, uncooperativeness, and depression (p< 0.001).

Overall, the most significant predictors of poor functional status one year after fracture were increasing age (p=0.005), living in an institution at time of injury (p=0.034), and poor functional status at discharge (p< 0.001).

Conclusions: In elderly women with a displaced intra-capsular hip fracture, total hip arthroplasty is associated with a functional benefit within the first months after surgery. However, the extent to which this functional benefit is maintained over time, is less clear. Our results support the need for randomised clinical trials among elderly women with a displaced intracapsular hip fracture to quantify the extent to which the early functional benefit of total hip arthroplasty is maintained in the long run or compromised by progressive cognitive impairment and other negative determinants of functional outcome.

Introduction: Fondaparinux, a selective inhibitor of activated factor X, has been shown to reduce further the risk of venous thromboembolism (VTE) in major orthopaedic surgery compared to the low molecular weight heparin enoxaparin, when both were applied for 7 days after surgery.

Aims: To compare the expected costs and clinical outcomes of fondaparinux with enoxaparin applied for 7 days after surgery, we conducted a cost-consequence analysis in patients undergoing major orthopaedic surgery, i.e. total hip replacement, total knee replacement and hip fracture repair.

Methods: Our decision model included endpoints relevant in routine clinical practice and the natural history of VTE over a long term period of 5 years. Costs for prevention, diagnosis and treatment of VTE and its complications were estimated from the Belgian health care payer perspective. Analyses were conducted for different time horizons and for the three indications, separately, and then combined.

Results: Overall, our results indicated that the initial investment in fondaparinux (cost per day: 10.39 Euros versus 3.74 Euros for enoxaparin) was soon compensated by savings due to avoided VTE events, with cost neutrality being achieved after 90 days and further savings being incurred over longer time periods mainly due to avoided post-thrombotic syndromes. These findings were most pronounced in patients undergoing hip fracture repair. Sensitivity analyses showed these findings to be robust for the three indications separately, and combined.

Conclusions: We conclude that our analysis of health and economic consequences over a long term period, demonstrates the value for money of fondaparinux versus enoxaparin for the prevention of VTE events after total hip replacement, total knee replacement and hip fracture repair.

Aims: To explore potential predictors of functional outcome after conservative treatment of acute fractures of the base of the fifth metatarsal. These fractures are the most frequent fracture of the foot. The factors that influence final clinical outcome are rarely investigated. Regression analysis regarding this problem was never performed.

Methods: The study design was observational and retrospective. Adults, conservatively treated for an acute fracture of the base of the fifth metatarsal included. All patients were given a plaster cast at the emergency department and were instructed not to bare weight (NWB) on the affected limb for at least one week. The further modalities of treatment were decided by individual surgeons according to their current clinical practice. A validated scoring system was used. Additional questions were asked about residual cosmetic and shoe problems and also about intensity of pain and the general feeling of comfort. The respective influences of factors on clinical outcome were examined using multiple linear and logistic regression modeling.

Results: 38 patients (11 men, 27 women) were analysed. The mean age was 48 years. 6 had a Jones fracture, while 32 had a tuberosity avulsion fracture. The mean non-weight bearing period was 2 weeks and 4 days (range 1 to 5 weeks) while the cast was worn for a mean of 5 weeks and 3 days (range 1 to 10 weeks). Three Jones fractures and all the avulsion fractures were healed at the end of treatment. The mean follow-up time was 298 days, ranging from 51 to 603 days. The mean result of the ankle score at follow-up was 77.5 (range 20 to 100). Thirteen of the 38 patients reported problems in wearing shoes. Only 8 patients experienced cosmetic problems. The mean linear analogue score for pain was 2.34, that for general comfort was 8.11. Overall, the most significant predictors of poor functional outcome at final follow-up evaluation were increasing duration of NWB and longer follow-up time. Longer NWB was importantly associated with worse global score, pain, comfort and reported stiffness. Neither gender nor fracture type had any significant influence on the overall clinical outcome.

Conclusions: The most important variable linked to final clinical outcome is the duration of the non-weight bearing period. Neither gender, age, length of casting nor even fracture type, had any significant influence on the overall clinical outcome. Therefore NWB should be kept to a minimum for acute avulsions.

Aims: We conducted an cost-utility analysis to compare standard (in-hospital) with prolonged (out-of-hospital) enoxaparin prophylaxis after elective total hip and knee replacement. Methods: The perspective was that of a societal healthcare payer, taking Belgium as a case country. The main outcome measure was the incremental cost-utility ratio, reported as the incremental cost per quality-adjusted life year gained (Euro/QALY). Costs for diagnosis and treatment of proximal and distal deep vein thrombosis, pulmonary embolism, postphlebitic syndrome, and major bleeding were obtained from a Delphi panel (orthopaedic surgeons) and the official reimbursement rates (Federal Ministery of Health). QALYs for these health states were based on utility scores as reported in the literature. Results: In the base-case analysis, incremental costs of prolonged prophylaxis amounted 58 Euro and 114 Euro per patient, with an additional gain in QALY of 0.0083 and 0.0018 after total hip and knee replacement, respectively. Thus, a strategy of prolonged enoxaparin prophylaxis was associated with a cost-utility ratio of 6,964 Euro/QALY and 64,907 Euro/QALY after total hip and knee replacement, respectively. Applying a societal willingness-to-pay threshold value of 20,000 Euro/QALY, prolonged enoxaparin prophylaxis is cost-effective after elective total hip replacement. Sensitivity analyses confirmed the general robustness of these findings. Conclusions: After elective total hip or knee replacement, prolonged enoxaparin prophylaxis leads to increased effectiveness at increased cost. Nevertheless, given the additional costs healthcare decision makers in Europe are usually prepared to pay for a gain in effectiveness, prolonged prophylaxis with enoxaparin is cost-effective after total hip replacement

Aims: The aim of our study was to compare relative risk of hip fracture after wrist or spine fracture, in both men and women. Methods: We performed a systematic literature review of cohort studies reported since 1982 that included low-trauma wrist or spine fracture as a risk factor for subsequent hip fracture among (white) women and men aged 50 years or older. A fixed effects meta-analysis was used to calculate a common relative risk (RR) with 95% confidence interval (95% CI). Results: Ten cohort studies (six from the U.S.A. and four from Europe) contributed to this meta-analysis. Among postmenopausal women, RRs for future hip fracture after wrist and spine fracture were 1.53 (95% CI 1.34–1.74, p< 0.001) and 2.22 (95% CI 1.95–2.52, p< 0.001), respectively. The RR was significantly higher after spine fracture than after wrist fracture (p< 0.001). Among ageing men, these RRs for future hip fracture were 3.26 (95% CI 2.08–5.11, p< 0.001) and 3.54 (95% CI 2.01–6.23, p< 0.001), respectively. In contrast to the observation in women, this difference was not statistically significant (p=0.82).

The RR was significantly higher in men than in women after wrist fracture (p=0.002), but not after spine fracture (p=0.12). Conclusions: Recent studies have shown consistent and strong prospective associations of hip fracture with previous wrist or spine fracture among postmenopausal women. The findings of our meta-analysis confirm these results and extend them to ageing men. In addition, our results indicate that wrist and spine fractures are equally important risk factors for future hip fracture in ageing men.

Aims:We conducted a prospective study among elderly women with a femoral neck fracture to determine if medical care costs during the one-year period after hospital discharge differ by surgical procedure type. In addition, we analysed potential predictors of costs. Methods: The design was a one-year prospective cohort study assessing day-to-day clinical practice. Eighty-four women were enrolled. Direct costs of care were documented during the oneyear period after hospital discharge and expressed in Euro (€) per hip-fracture patient. Multiple regression analyses were performed to explore potential predictors of costs. Results: Three fracture groups were defined by the type of surgical repair. Total-hiparthroplasty patients were significantly younger than hemiarthroplasty or internal-fixation patients (median age 71, 81, and 80 years, respectively; p = 0.001). Average costs during the one-year follow up period after hospital discharge were lower after total hip arthroplasty (e 9,486) than after hemiarthroplasty (€ 12,146) or internal fixation (€ 15,687), although these trends failed to achieve the level of statistical significance (p = 0.322). A multivariate regression model identified two significant determinants of increased costs: increasing age (p = 0.023) and living in an institution at time of injury (p = 0.004). Conclusions: Direct costs of care during the one-year period after hospital discharge among elderly women with a femoral neck fracture do not depend on the type of surgical procedure. Increasing age and living in an institution at time of injury, on the other hand, are strong predictors of increased costs during the one-year period after hospital discharge.