Primary nonunion of intertrochanteric fractures of femur: An analysis of results of valgization and bone grafting

Background:

Nonunion of intertrochanteric fractures is uncommon because there is excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). There is only one published series that exclusively describes seven primary nonunions of intertrochanteric fractures. The aim of the present study was to analyze the results of internal fixation, valgization with 135° dynamic hip screw (DHS), and bone grafting in patients with primary nonunion of intertrochanteric fractures.

Materials and Methods:

Eighteen patients with primary intertrochanteric nonunion were included in the study; 16 were male and 2 were female. The age range was 30–70 years (mean: 46.9 years). The mean duration since index injury was 8.5 months (range: 4–18 months). As per the AO classification, the fractures were 31A 1.1 (n=1), 1.2 (n=1), 2.2 (n=3), 2.3 (n=9), and 3.3 (n=4). Three patients had hypermobile nonunion and 15 had stiff nonunion. The surgical principle was excision of pseudarthrosis, if present (n=3); freshening of the bone ends; stable fixation with 135° DHS, with good proximal purchase; bone grafting; and valgization.

Results:

Union was achieved in all patients at an average of 5.62 months (range: 4–7 months). The Harris hip score improved from 38 points preoperatively to 86 postoperatively at healing. The average limb shortening improved by 2 cm (range: 1.5 cm–3 cm). There was no infection and pain at the hip at final follow-up in any of the cases. All patients were subjectively satisfied with the outcome. All were capable of full weight bearing on their affected limb.

Conclusion:

Union in primary nonunion of intertrochanteric fractures in physiologically young patients with a well-preserved femoral head and good bone stock can be achieved with internal fixation, valgization, and grafting procedures.     

A methodological framework for estimating the clinical and economic value of community pharmacists' clinical interventions using expert opinion

What is known and Objective: Studies of the outcomes of clinical interventions (CIs) performed by community pharmacists are limited. The economic models used in most studies of CIs have been simplistic, often failing to fully capture the counterfactual when estimating savings in health resources resulting from CIs. This paper aimed to describe the complexities involved in estimating the clinical and economic outcomes of CIs performed by community pharmacists when using expert opinion and suggest avenues for improvement. Methods: Existing models were reviewed, from which a range of key parameters required to evaluate the outcomes of CIs were identified. The considerations necessary to generate potentially more robust estimates of these parameters were discussed. Results and Discussion: CIs performed by community pharmacists may result in a multitude of effects on numerous health services. By utilizing the approaches described in this paper, researchers working in this field should be able to generate improved estimates of health resource savings and quality of life effects resulting from CIs performed by community pharmacists, when compared to previous efforts. What is new and Conclusion: This article offers recommendations designed to improve the robustness of evaluation when using expert opinion to evaluate CIs performed by community pharmacists.     

The potential for intelligent decision support systems to improve the quality and consistency of medication reviews

What is known and Objective: Drug‐related problems (DRPs) are of serious concern worldwide, particularly for the elderly who often take many medications simultaneously. Medication reviews have been demonstrated to improve medication usage, leading to reductions in DRPs and potential savings in healthcare costs. However, medication reviews are not always of a consistently high standard, and there is often room for improvement in the quality of their findings. Our aim was to produce computerized intelligent decision support software that can improve the consistency and quality of medication review reports, by helping to ensure that DRPs relevant to a patient are overlooked less frequently. A system that largely achieved this goal was previously published, but refinements have been made. This paper examines the results of both the earlier and newer systems. Methods: Two prototype multiple‐classification ripple‐down rules medication review systems were built, the second being a refinement of the first. Each of the systems was trained incrementally using a human medication review expert. The resultant knowledge bases were analysed and compared, showing factors such as accuracy, time taken to train, and potential errors avoided. Results and Discussion: The two systems performed well, achieving accuracies of approximately 80% and 90%, after being trained on only a small number of cases (126 and 244 cases, respectively). Through analysis of the available data, it was estimated that without the system intervening, the expert training the first prototype would have missed approximately 36% of potentially relevant DRPs, and the second 43%. However, the system appeared to prevent the majority of these potential expert errors by correctly identifying the DRPs for them, leaving only an estimated 8% error rate for the first expert and 4% for the second. What is new and conclusion: These intelligent decision support systems have shown a clear potential to substantially improve the quality and consistency of medication reviews, which should in turn translate into improved medication usage if they were implemented into routine use.     

Musculoskeletal Chronic Graft versus Host Disease—A Rare Complication to Allogeneic Hematopoietic Stem Cell Transplant: A Case-Based Report and Review of the Literature

Musculoskeletal graft versus host disease (GVHD) is a rare manifestation of chronic GVHD (cGVHD) following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Left untreated, the disease can cause extensive damage to muscle tissue and joints. We describe a 62-year-old male with musculoskeletal GVHD and generalized muscle pain and stiffness. In addition, we performed a systemic literature review based on published cases of musculoskeletal GVHD between 1983 and 2019. We identified 85 cases, 62% male and 38% female with an age of 4–69 years and median age of 39 years at diagnosis. The majority of patients (72%) also had manifestations of cGVHD in at least one other organ system, most frequently the skin (52%), followed by oropharyngeal mucosa (37%), and pulmonary and gastrointestinal tract (GI tract) (21%). We conclude that, while musculoskeletal cGVHD is a rare complication of allo-HSCT, it remains a serious and debilitating risk that must be considered in patients with muscle pain, muscle weakness, joint stiffness, and tissue inflammation. Early intervention is critical for the patient’s prognosis.