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1.  Transfer of either index finger extensor tendon to the extensor pollicis longus tendon 
BACKGROUND:
Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method.
OBJECTIVES:
To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand.
METHODS:
Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles’ fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery.
RESULTS:
All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side.
CONCLUSIONS:
These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.
PMCID: PMC3792765  PMID: 24115870
Extensor digitorum communis II (EDC II); Extensor indicis proprius (EIP); Extensor pollicis longus (EPL); Rupture; Tendon transfer
2.  Abnormal bone remodelling in inflammatory arthritis 
Canadian Journal of Surgery  1998;41(4):264-271.
Osteopenia is responsible for substantial comorbidity in patients suffering from rheumatoid arthritis and is an important factor in the surgical management of joint disease. In animal models of bone loss stimulated by inflammatory arthritis, increased bone remodelling and altered microstructure of bone have been documented. The subchondral bone plate near the joint surface is narrow and perforated by vascular inflammatory invasion, and in the shaft the thin cortices are weakened by giant resorption defects. Biomechanical tests and a mathematical model of bone strength suggest that cortical defects, much larger than those found in normal osteonal remodelling, are principally responsible for the experimentally observed loss of strength. Similarly, these defects may explain the increased femoral fracture risk in rheumatoid arthritis.
The osteoclast, the cell resorbing bone, is demonstrated in increased number and activity in rheumatoid arthritis and in animal models. Bisphosphonates, drugs that inhibit osteoclast function, have been shown experimentally to reduce both focal and generalized osteopenia and to prevent loss of bone strength. Bisphosphonates also protect articular cartilage from damage characteristic of inflammatory arthritis. The mechanism of chondroprotection may be prevention of subchondral bone resorption by the osteoclast and also an altered distribution of bone marrow cells. Thus, bisphosphonates, currently in clinical use for other bone metabolic diseases, appear to have potential as prophylaxis and treatment for osteopenia and joint damage in inflammatory arthritis.
PMCID: PMC3950080  PMID: 9711159
4.  Insufficient Flexion of the Metacarpophalangeal Joint of the Little Finger Following Swanson Silicone Arthroplasty for Rheumatoid Arthritis 
Hand (New York, N.Y.)  2007;3(1):24-29.
Twenty-one patients with rheumatoid arthritis who underwent Swanson metacarpophalangeal (MP) arthroplasty from 1994 to 1999 were assessed for active flexion of individual MP joints an average of 59 months (range 27–114 months) postoperative. Published articles of Swanson MP arthroplasty were reviewed. Experienced hand surgeons were surveyed regarding outcomes of metacarpophalangeal arthroplasty. The MP joint of the little finger displayed significantly less flexion than that of the middle and index finger. Seven of eight published studies which present active MP flexion by individual digit demonstrated less flexion in the little finger compared to the index, middle, and ring finger. Half of surgeons surveyed reported that MP range of motion is shifted toward a more extended position, that MP flexion is limited in the ulnar digits, and that an implant that encourages MP flexion would be helpful. Our experience with this cohort, a review of published literature, and a survey of international experts suggest that Swanson arthroplasty frequently results in a range of flexion of the MP joint of the little finger that may be insufficient for its principal functions.
doi:10.1007/s11552-007-9051-5
PMCID: PMC2528972  PMID: 18780116
Metacarpophalangeal joint; Arthroplasty, replacement, finger; Arthritis, rheumatoid; Range of motion, articular; Little finger
5.  Quality of Life After TKA for Patients With Juvenile Rheumatoid Arthritis 
Total knee arthroplasty frequently is required during early adulthood in patients with advanced juvenile rheumatoid arthritis. We queried patients on issues of importance to them, asked whether they were satisfied with surgical outcomes, and ascertained their postoperative status. We retrospectively reviewed 14 adult patients (22 knees) with severe juvenile rheumatoid arthritis who were treated with primary total knee arthroplasty between 1989 and 2001. All patients were evaluated by pain and stiffness visual analog scales, range of motion, the Patient-Specific Index, Hospital for Special Surgery knee score, WOMAC Osteoarthritis Index, EuroQuol in five dimensions, and SF-36 Health Survey. Preoperative scores were assessed by recall. Patients had a minimum followup of 2 years (mean, 8 years; range, 2–13 years). Quality of life improved after TKA as measured by the Patient-Specific Index. Eighteen of 22 patients rated themselves satisfied with the functional outcome of their surgery; all patients were satisfied with pain relief. Final SF-36, EuroQuol in five dimensions, and WOMAC scores were low compared with age-matched population norms. A mean postoperative flexion arc of 77° (range, 30°–130°) was observed. Total knee arthroplasty had a major positive impact on quality of life as reported by patients.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-007-0010-9
PMCID: PMC2505301  PMID: 18196390
6.  Improving patient satisfaction with time spent in an orthopedic outpatient clinic 
Canadian Journal of Surgery  2000;43(6):431-436.
Objective
To determine if patient satisfaction can be improved by changing patients’ expectations of the clinic visit and by decreasing the total time spent in the clinic.
Design
A prospective comparative analysis carried out in 4 phases.
Setting
An university-affiliated orthopedic outpatient clinic.
Patients
All patients seen in the orthopedic outpatient clinic were eligible. Phase 1 determined the total clinic time required by patient type; phase 2 assessed baseline satisfaction; phase 3 altered patients’ expectations; and phase 4 altered patients’ expectations and scheduled visits by patient type.
Intervention
Patient questionnaires.
Main outcome measure
Patient satisfaction with time spent in the clinic.
Results
Of 708 distributed questionnaires, 622 (88%) were completed (547 totally complete, 75 partially complete). Total time spent in the clinic decreased across phases 2, 3 and 4 (mean 99.2, 94.7 and 85.2 minutes, respectively, but was significantly different only between phases 3 and 4; p = 0.05, Duncan’s multiple range test). The percentage of patients who rated their waiting time as “excellent” increased across phases 2, 3 and 4 (14.6%, 18.8% and 31.1%, respectively; p = 0.0004, χ2 test).
Conclusion
Patient satisfaction can be improved by altering patient expectations and by decreasing the total time spent in clinic.
PMCID: PMC3695198  PMID: 11129831
7.  Investigation and treatment of osteoporosis in patients with fragility fractures 
Background
Many patients who have undiagnosed osteoporosis and a recent fragility fracture present to fracture clinics in Canadian hospitals, where the focus of management is on fracture care. The rate of diagnosis and treatment of osteoporosis in this patient group is unknown.
Methods
Patients who presented with fractures at sites consistent with fragility-type fractures were identified through a retrospective chart review of fracture clinic visits in 3 Ontario community hospitals in selected weeks in February and November 1996 and August and May 1997. These patients were contacted by mail and telephone follow-up to obtain consent to participate in a telephone interview. Patients were excluded if the index fracture had been traumatic, if they were younger than 18 years, or if they had medical conditions known to be associated with secondary bone loss. Eligible patients were questioned about their history of prior fractures, diagnosis of osteoporosis, and investigation and treatment of osteoporosis before or after the index fracture.
Results
Among 2694 fracture clinic visits, we identified 228 patients (8.4%) with fragility-type fractures. Of the 228, 128 (56.1%) were contacted and agreed to participate in an interview about 1 year from the date of the index fracture. Of the 128 patients, 108 (83 postmenopausal and 13 premenopausal women and 12 men) were confirmed as eligible. Of the 108, 43 had experienced 53 fractures in addition to the index fracture in the preceding 10 years, of which 71% were of the fragility type. At interview, only 20 (18.5%) (all postmenopausal women) of the 108 patients reported that they had received a diagnosis of osteoporosis. Of the 20, 90% and 45% respectively had been advised to take calcium and vitamin D supplements; 8 (40%) were receiving hormone replacement therapy (HRT), and 8 (40%) were taking bisphosphonates. Of the 88 patients who had not received a diagnosis of osteoporosis, 4 (4.5%) were receiving HRT, none was taking bisphosphonates, and less than 20% had been advised to take supplemental calcium or vitamin D.
Interpretation
In a representative sample of patients at urban fracture clinics, less than 20% who presented with a fragility-type fracture had undergone investigatation and adequate treatment of osteoporosis at 1-year follow-up. Since previous fracture significantly increases the risk for future fracture, this clearly is a deficiency in management. Through improved identification and treatment of patients with osteoporosis-related fractures who present to fracture clinics, there is a significant opportunity to reduce the rates of illness and death associated with this conditio
PMCID: PMC80503  PMID: 11033708
8.  A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients 
Canadian Journal of Surgery  2008;51(1):8-14.
Objective
The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients.
Methods
A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association.
Results
Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients.
Conclusion
Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients.
PMCID: PMC2386310  PMID: 18248700
9.  Bone mineral density testing after fragility fracture 
Canadian Family Physician  2013;59(12):e564-e571.
Abstract
Objective
To determine the proportion of patients with fragility fractures who can be expected to have low bone mineral density (BMD) at the time of fracture and to assist FPs in deciding whether to refer patients for BMD testing.
Data sources
MEDLINE, EMBASE, and CINAHL were searched from the earliest available dates through September 2009.
Study selection
English-language articles reporting BMD test results of patients with fragility fractures who were managed in an orthopedic environment (eg, fracture clinic, emergency management by orthopedic surgeons, inpatients) were eligible for review. While the orthopedic environment has been identified as an ideal point for case finding, FPs are often responsible for investigation and treatment. Factors that potentially influenced BMD test results (eg, selection of fracture types, exclusion criteria) were identified. Studies with 2 or more selection factors of potential influence were flagged, and rates of low BMD were calculated including and excluding these studies.
Synthesis
The distribution of the proportion of persons with low BMD was summarized across studies using descriptive statistics. We calculated lower boundaries on this distribution, using standard statistical thresholds, to determine a lower threshold of the expected rate of low BMD.
Conclusion
Family physicians evaluating patients with fragility fractures can expect that at least two-thirds of patients with fragility fractures who are older than 50 years of age will have low BMD (T score ≤ −1.0). With this a priori expectation, FPs might more readily conduct a fracture risk assessment and pursue warranted fracture risk reduction strategies following fragility fracture.
PMCID: PMC3860947  PMID: 24336562

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