Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

Background

Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality of care received in this group. We evaluated whether socioeconomic deprivation affected the complications and subsequent management of marginalized/homeless patients following surgery for ankle fracture.

Methods

In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45 444 patients who underwent open reduction and internal fixation (ORIF) for ankle fracture performed by 710 different surgeons between Jan. 1, 1994, and Dec. 31, 2011. Multivariable logistic regression models were used to assess the association between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and débridement owing to infection, and amputation). Multivariable Cox proportional hazards models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty).

Results

A higher level of deprivation was associated with an increased risk of irrigation and débridement (quintile 5 v. quintile 1: odds ratio [OR] 2.14, 95% confidence interval [CI] 1.25–3.67, p = 0.0054) and amputation (quintile 4 v. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed (quintile 5 v. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty.

Conclusion

Marginalized patients are at a significantly increased risk of infection and amputation following surgical treatment of ankle fractures. However, these complications are still extremely uncommon among this group. Socioeconomic deprivation should not prohibit marginalized patients from receiving surgery for unstable ankle fractures.

Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: A Propensity Score-Matched, Population-Based Study

BACKGROUND

Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.

METHODS

A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.

RESULTS

Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).

CONCLUSIONS

Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medical Costs of Delayed Hip Fracture Surgery

BACKGROUND

Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs.

METHODS

We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days).

RESULTS

The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours.

CONCLUSIONS

Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery.

LEVEL OF EVIDENCE

Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.

The impact of thermal cycling on Staphylococcus aureus biofilm growth on stainless steel and titanium orthopaedic plates

Background

Orthopaedic implant infections are difficult to eradicate because bacteria adhering to implant surfaces inhibit the ability of the immune system and antibiotics to combat these infections. Thermal cycling is a temperature modulation process that improves performance and longevity of materials through molecular structural reorientation, thereby increasing surface uniformity. Thermal cycling may change material surface properties that reduce the ability for bacteria to adhere to the surface of orthopaedic implants. This study aims to determine whether thermal cycling of orthopaedic implants can reduce bacterial growth.

Methods

In a randomized, blinded in-vitro study, titanium and stainless steel plates treated with thermal cycling were compared to controls. Twenty-seven treated and twenty-seven untreated plates were covered with 10 ml tryptic soy broth containing ~ 10⁵ colony forming units (CFU)/ml of bioluminescent Staphylococcus aureus (S. aureus)Xen29 and incubated at 37 °C for 14d. Quantity and viability of bacteria were characterized using bioluminescence imaging, live/dead staining and determination of CFUs.

Results

Significantly fewer CFUs grow on treated stainless steel plates compared to controls (p = 0.0088). Similar findings were seen in titanium plates (p = 0.0048) following removal of an outlier. No differences were evident in live/dead staining using confocal microscopy, or in metabolic activity determined using bioluminescence imaging (stainless steel plates: p = 0.70; titanium plates: p = 0.26).

Conclusion

This study shows a reduction in CFUs formation on thermal cycled plates in-vitro. Further in-vivo studies are necessary to investigate the influence of thermal cycling on bacterial adhesion during bone healing. Thermal cycling has demonstrated improved wear and strength, with reductions in fatigue and load to failure. The added ability to reduce bacterial adhesions demonstrates another potential benefit of thermal cycling in orthopaedics, representing an opportunity to reduce complications following fracture fixation or arthroplasty.

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada

BACKGROUND

Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them.

METHODS

Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models.

RESULTS

Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery.

INTERPRETATION

Exact wait times for urgent and emergent surgery can be measured using Canada's administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

Reliability of the classification of proximal femur fractures: Does clinical experience matter?

BACKGROUND

Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master.

QUESTIONS/PURPOSES

We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup.

METHODS

This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons.

RESULTS

There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001).

CONCLUSIONS

This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Open Reduction and Internal Fixation Versus Acute Arthroplasty for the Management of Common Extremity Injuries: Evidence-Based Decision Making

A considerable burden of disease is associated with the management of periarticular fractures. Increasingly, evidence-based medicine is used to define the standard of clinical care. The role of internal fixation in the management of periarticular fractures, particularly in elderly patients, has been questioned. Currently available evidence-based medicine studies may help surgeons decide whether open reduction and internal fixation or arthroplasty is appropriate for the management of common periarticular injuries. The management of periarticular injuries about the shoulder, elbow, hip, and knee is controversial. The long-term outcomes of patients with a periarticular upper or lower extremity injury who undergo open reduction and internal fixation are limited by high complication and revision surgery rates and poor functional outcomes. Despite evidence-based medicine decision making and the substantial number of prospective clinical trials available in the literature, a lack of consensus with regard to best practices for the surgical management of periarticular injuries exists. This lack of consensus has substantial implications given that proximal humerus, elbow, hip, and knee fractures are common and that the role of acute arthroplasty in the management of periarticular injuries is changing.

Exploring Canadian surgeons' decisions about postoperative weight bearing for their hip fracture patients

For older adults with osteoporosis, a fall resulting in hip fracture is a life-changing event from which only one-third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue "weight-bearing-as-tolerated" (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long-term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight-bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight-bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have "rules to break the rules." In an era when "good" medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly.

Association of Overlapping Surgery With Increased Risk for Complications Following Hip Surgery: A Population-Based, Matched Cohort Study

IMPORTANCE

Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.

OBJECTIVE

To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The "hip fracture" cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The "total hip arthroplasty" (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.

EXPOSURES

Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.

MAIN OUTCOMES AND MEASURES

Complication (infection, revision, dislocation) within 1 year.

RESULTS

There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).

CONCLUSIONS AND RELEVANCE

Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.

Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery

IMPORTANCE

Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications.

OBJECTIVE

To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases.

DESIGN, SETTING, AND PARTICIPANTS

Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs).

EXPOSURE

Time elapsed from hospital arrival to surgery (in hours).

MAIN OUTCOMES AND MEASURES

Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia).

RESULTS

Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89).

CONCLUSIONS AND RELEVANCE

Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

Discharge destination following hip fracture: comparative effectiveness and cost analyses

This study determines outcomes and costs of similar hip fracture patients that were discharged from hospital to a rehabilitation facility or to the community within 1 year. Community patients had worse outcomes and lower costs compared to rehabilitation facility patients. This study contributes to understanding hip fracture quality of care.

PURPOSE

The purpose of this study is to determine the impact on mortality and rehospitalization, as well as health system cost, of similar hip fracture patients being discharged to an inpatient rehabilitation facility or directly to the community within 1 year in Ontario, Canada.

METHODS

This was a retrospective study of a propensity-matched cohort completed from the health system perspective. Administrative databases were used to identify and match two groups of older adults (total n = 18,773) discharged alive from acute care for hip fracture repair: patients discharged to inpatient rehabilitation were matched to patients discharged to the community.

RESULTS

A higher proportion of patients discharged to the community (27-42%) died or were rehospitalized (SD_highipr = 0.21, SD_lowipr = 0.33) and had substantially lower health system costs (SD_highipr = 0.65, SD_lowipr = 0.42) up to 1 year post-acute discharge compared to similar patients discharged to inpatient rehabilitation facilities (IPR) (10-11%).

CONCLUSIONS

This study demonstrates that similar hip fracture patients are discharged to different post-acute settings (i.e., home-based rehabilitation and inpatient rehabilitation) and have different outcomes, thereby calling into question the appropriateness of post-acute rehabilitation delivery in Ontario, Canada. Future research should focus on determining how trade-offs in resource allocation between settings would impact patient outcomes.

Outcomes of After-Hours Hip Fracture Surgery

BACKGROUND

Given single-institution studies showing trends between after-hours hip fracture surgical procedures and adverse outcomes, as well as fixation time targets that may increasingly compel after-hours operations, we investigated the relationship between after-hours hip fracture surgical procedures and adverse outcomes in a large, population-based cohort.

METHODS

All Ontarians who were ≥60 years of age and underwent a hip fracture surgical procedure between April 2002 and March 2014 were eligible for study inclusion. Data were obtained from linked health administrative databases. The primary exposure was after-hours provision of surgical procedures, occurring weekday evenings between the hours of 5 P.M. and 12 A.M. or over the weekend, but not overnight (after 12 A.M. to 7 A.M.). Surgical complications up to 6 months following a hip fracture surgical procedure comprised the primary outcome. Medical complications, including mortality, up to 90 days postoperatively were also assessed. Odds ratios (ORs) were calculated using a logistic regression model that accounted for clustering at the hospital level and adjusted for patient, provider, and fracture characteristics previously shown to explain the majority of variance in hip fracture outcomes.

RESULTS

During the study period, 87,647 patients underwent an isolated hip fracture surgical procedure; 51.2% of these patients had femoral neck fractures, 44.1% had intertrochanteric fractures, and 4.7% had subtrochanteric fractures. The surgical procedure occurred after hours in 59,562 patients (68.0%), and 27,240 patients (31.1%) underwent a surgical procedure during normal hours (7 A.M. to 5 P.M.). Only 845 patients (1%) underwent a surgical procedure overnight. We observed no significant relationships between timing of the surgical procedure and adverse outcomes, except for patients who had undergone an after-hours surgical procedure and had fewer inpatient surgical complications (OR, 0.90 [95% confidence interval, 0.83 to 0.99]; p = 0.01).

CONCLUSIONS

Adverse outcomes following a hip fracture surgical procedure were similar whether a surgical procedure occurred during normal hours or after hours. Concerns regarding the quality of after-hours surgical procedures should not influence hip fracture prioritization policy. However, given that the great majority of hip fracture surgical procedures occurred after hours, future research should examine other potential consequences of this practice, such as financial impact and surgeon burnout.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-Irrigator-Aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures

OBJECTIVES

We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures.

DESIGN

Prospective randomized clinical trial.

SETTING

Multi-centered trial, level I trauma centers.

PATIENTS/PARTICIPANTS

All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group.

INTERVENTION

Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli.

MAIN OUTCOME MEASURE

Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative.

RESULTS

There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2).

CONCLUSIONS

This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Prescription Opioid Use 4 Months After Traumatic Musculoskeletal Injury and Corrective Surgery: A Prospective Study

The aim of the present study was to examine the incidence and predictors of persistent prescription opioid use 4 months after traumatic injury. Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4 months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information. The sample consisted of 122 patients (66.4% male; mean age = 44.8 years, SD = 17.1), of whom 94.3% (n = 115) were using prescription opioids. At T2, 35.3% (n = 43) patients were using prescription opioids. After controlling for age, sex, injury severity, T1 pain severity, and T2 symptoms of depression, 2 factors emerged as significantly related to T2 prescription opioid use; namely, T2 pain severity (odds ratio = 1.248, 95% confidence interval, 1.071-1.742) and T2 pain self-efficacy (odds ratio = .943, 95% confidence interval, .903-.984). These results suggest that opioid use after traumatic musculoskeletal injury is related to pain severity and how well patients cope specifically with their pain, over and above other psychological factors, such as depression and anxiety.

PERSPECTIVE

This article identifies predictive factors for prescription opioid use after traumatic musculoskeletal injury, namely severe pain and a poor sense of control over the pain. These results highlight the importance of using prospective longitudinal study designs to understand why patients continue to use prescription opioids after major tissue-damaging events.

Post-acute pathways among hip fracture patients: a system-level analysis

BACKGROUND

Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system.

METHODS

This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values.

RESULTS

Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region.

CONCLUSIONS

The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.

Thermal cycling can extend tool life in orthopaedic operating rooms

Thermal cycling is a temperature modulation process developed to improve the performance, durability and longevity of materials. This process has been successfully utilized in the automotive, aeronautic and manufacturing industries. Surgical cutting tools undergo cyclical loading and generally fail by dulling, suggesting that thermal cycling may improve their performance and longevity. Ten 2.5 mm orthopaedic drill bits were randomized, with five undergoing thermal cycling within their sterile packaging and five serving as untreated controls. Using a servohydraulic testing machine, 100 drilling cycles were performed with each drill bit into the diaphyseal region of bovine femurs. After every 25 cycles, data was collected by performing identical drilling cycles into simulated human cortical bone material. Maximum force, maximum normalized torque and drilling work were measured, and a scanning electron microscope was used to measure outer corner wear. After 100 drilling cycles, the maximum drilling force, maximum normalized torque, drilling work and microscopic outer corner wear were all significantly lower for the treated drill bits (p < 0.05). Thermal cycling has the potential to decrease operating room costs and thermal necrosis associated with dull cutting tools. Application of this technology may also be relevant to surgical cutting tools such as saw blades, burrs and reamers.

Radiotherapy for the prophylaxis of heterotopic ossification: a systematic review and meta-analysis of published data

INTRODUCTION

Following surgery, the formation of heterotopic ossification (HTO) can limit mobility and impair quality of life. Radiotherapy has been proven to provide efficacious prophylaxis against HTO, especially in high-risk settings.

PURPOSE

The current review aims to determine the factors influencing HTO formation in patients receiving prophylactic radiotherapy.

METHODS

A systematic search of the literature was conducted on Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Studies were included if they reported the percentage of sites developing heterotopic ossification after receiving a specified dose of prophylactic radiotherapy. Weighted linear regression analysis was conducted for continuous or categorical predictors.

RESULTS

Extracted from 61 articles, a total of 5464 treatment sites were included, spanning 85 separate study arms. Most sites were from the hip (97.7%), from United States patients (55.2%), and had radiation prescribed postoperatively (61.6%) at a dose of 700cGy (61.0%). After adjusting for radiation site, there was no statistically significant relationship between the percentage of sites developing HTO and radiation dose (p=0.1) or whether radiation was administered preoperatively or postoperatively (p=0.1). Sites with previous HTO formation were more likely to develop recurrent HTO than those without previous HTO formation (p=0.04). There was a statistically significant negative relationship between the HTO development and the cohort mean year of treatment (p=0.007).

CONCLUSION

Decreases in rates of HTO over time in this patient population may be a function of more efficacious surgical regimens and prophylactic radiotherapy.

Reoperations after tarsal coalition resection: a population-based study

Few studies have evaluated the incidence of subsequent operations after tarsal coalition resection. Using administrative databases, we followed up a cohort of patients who had undergone tarsal coalition resection to determine the rates and possible risk factors for subsequent resection or arthrodesis. Patients (aged 8 years or older) who had been treated from July 1994 to August 2009 in Canada were identified and included. Those with nonidiopathic coalitions were excluded. The time-to-event data for the earliest subsequent procedure were fit to a Cox proportional hazards model that evaluated the patient, operative, and provider factors. Controlling for covariates, the hazard ratios were computed; however, the laterality of any subsequent operation could not be confirmed. A total of 304 patients underwent tarsal coalition resection at an average age of 24.2 ± 17.5 years. Of these 304 patients, 26 (8.6%) underwent subsequent resection and 16 (5.3%) mid- or hindfoot arthrodesis. Of all the factors, the need for future fusion was more likely only if the primary resection had been performed at an academic hospital or if the patient had undergone concomitant arthrodesis at primary resection of the coalition (hazard ratio 3.0, 95% confidence interval 1.1 to 8.5; and hazard ratio 9.7, 95% confidence interval 1.7 to 56.1, respectively). The incidence of reoperation after primary tarsal coalition resection was low in our cohort. More than 85% of our patients never required additional operative intervention an average of 9 years after the initial resection. Our data also suggest that primary treatment of tarsal coalition with resection and concomitant arthrodesis increases the risk of requiring a second fusion in the future.

Symptomatic venous thromboembolism uncommon without thromboprophylaxis after isolated lower-limb fracture: the knee-to-ankle fracture (KAF) cohort study

BACKGROUND

The prevalence of deep vein thrombosis as demonstrated by routine venography in patients with distal lower-extremity injury requiring cast immobilization or surgery is 10% to 40%. These deep vein thromboses are usually asymptomatic and distal, and the need for thromboprophylaxis in these patients is not known.

METHODS

We conducted a multicenter prospective cohort study to define the prevalence of symptomatic venous thromboembolism in patients with a tibial, fibular, or ankle fracture (treated nonoperatively) or a patellar or foot fracture (treated operatively or conservatively). Consecutive patients were enrolled at five Ontario, Canada, hospitals within ninety-six hours after injury, and they were followed with a telephone interview at two, six, and twelve weeks. Thromboprophylaxis was not allowed. Suspected venous thromboembolism was investigated in a standardized manner.

RESULTS

From August 2002 to June 2005, 1200 patients were enrolled, and a three-month follow-up was completed for 98% of them. Eighty-two percent of the patients were treated with cast or splint immobilization for an average (and standard deviation) of 42 ± 32 days. Overall, seven patients (0.6%; 95% confidence interval [CI] = 0.2% to 1.2%) had symptomatic, objectively confirmed venous thromboembolism. Two of them had proximal deep vein thrombosis; three, calf deep vein thrombosis; and two, pulmonary embolism. There were no fatal pulmonary emboli.

CONCLUSIONS

Symptomatic venous thromboembolism is an infrequent complication after fractures of the distal part of the lower limb requiring cast immobilization and managed without thromboprophylaxis. Given these estimates of symptomatic venous thromboembolism, the risk-benefit ratio and cost-effectiveness of routine anticoagulant prophylaxis are unlikely to be favorable for these patients.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Delayed debridement of severe open fractures is associated with a higher rate of deep infection

This study explores the relationship between delay to surgical debridement and deep infection in a series of 364 consecutive patients with 459 open fractures treated at an academic level one trauma hospital in North America. The mean delay to debridement for all fractures was 10.6 hours (0.6 to 111.5). There were 46 deep infections (10%). There were no infections among the 55 Gustilo-Anderson grade I open fractures. Among the grade II and III injuries, a statistically significant increase in the rate of deep infection was found for each hour of delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows a linear increase of 3% per hour of delay. No distinct time cut-off points were identified. Deep infection was also associated with tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects are additive, which suggests that delayed debridement will have a clinically significant detrimental effect on more severe open fractures. Delayed treatment appeared safe for grade 1 open fractures. However, when the negative prognostic factors of tibial site, high grade of fracture and/or contamination are present we recommend more urgent operative debridement.

Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study

BACKGROUND

Primary closure of skin wounds after debridement of open fractures is controversial. The purpose of the present study was to determine whether primary skin closure for grade-IIIA or lower-grade open extremity fractures is associated with a lower deep-infection rate.

METHODS

We identified 349 Gustilo-Anderson grade-I, II, or IIIA fractures treated at our level-I academic trauma center from 2003 to 2007. Eighty-seven injuries were treated with delayed primary closure, and 262 were treated with immediate closure after surgical debridement. After application of a propensity score-matching algorithm to balance prognostic factors, 146 open fractures (seventy-three matched pairs) were analyzed.

RESULTS

After application of a propensity score-matching algorithm with adjustment for age, sex, time to debridement, American Society of Anesthesiologists (ASA) class, fracture grade, evidence of gross contamination, and a tibial fracture rather than a fracture at another anatomic site, the two treatment groups were compared with respect to the prevalence of infection. Deep infection developed at the sites of three of the seventy-three fractures treated with immediate closure (infection rate, 4.1%; 95% confidence interval [CI], 0.86 to 11.5) compared with thirteen in the matched group of seventy-three fractures treated with delayed primary closure (infection rate, 17.8%; 95% CI, 9.8 to 28.5) (McNemar test, p = 0.0001).

CONCLUSIONS

Immediate closure of carefully selected wounds by experienced surgeons treating grade-I, II, and IIIA open fractures is safe and is associated with a lower infection rate compared with delayed primary closure.

Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-population-based cohort study

BACKGROUND

The aims of operative treatment of displaced tibial plateau fractures are to stabilize the injured knee to restore optimal function and to minimize the risk of posttraumatic arthritis and the eventual need for total knee arthroplasty. The purpose of our study was to define the rate of subsequent total knee arthroplasty after tibial plateau fractures in a large cohort and to compare that rate with the rate in the general population.

METHODS

All patients sixteen years of age or older who had undergone surgical treatment of a tibial plateau fracture from 1996 to 2009 in the province of Ontario, Canada, were identified from administrative health databases with use of surgeon fee codes. Each member of the tibial plateau fracture cohort was matched to four individuals from the general population according to age, sex, income, and urban/rural residence. The rates of total knee arthroplasty at two, five, and ten years were compared by using time-to-event analysis. A separate Cox proportional hazards model was used to explore the influence of patient, provider, and surgical factors on the time to total knee arthroplasty.

RESULTS

We identified 8426 patients (48.5% female; median age, 48.9 years) who had undergone fixation of a tibial plateau fracture and matched them to 33,698 controls. The two, five, and ten-year rates of total knee arthroplasty in the plateau fracture and control cohorts were 0.32% versus 0.29%, 5.3% versus 0.82%, and 7.3% versus 1.8%, respectively (p < 0.0001). After adjustment for comorbidity, plateau fracture surgery was found to significantly increase the likelihood of total knee arthroplasty (hazard ratio [HR], 5.29 [95% confidence interval, 4.58, 6.11]; p < 0.0001). Higher rates of total knee arthroplasty were also associated with increasing age (HR, 1.03 [1.03, 1.04] per year over the age of forty-eight; p < 0.0001), bicondylar fracture (HR, 1.53 [1.26, 1.84]; p < 0.0001), and greater comorbidity (HR, 2.17 [1.70, 2.77]; p < 0.001).

CONCLUSIONS

Ten years after tibial plateau fracture surgery, 7.3% of the patients had had a total knee arthroplasty. This corresponds to a 5.3 times increase in likelihood compared with a matched group from the general population. Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture.

Quantitative measures of damage to subchondral bone are associated with functional outcome following treatment of displaced acetabular fractures

Current analysis of displaced acetabular fractures is limited in its ability to predict functional outcome. This study aimed to (1) quantify initial acetabular damage following acetabular fracture through measurement of subchondral bone density and fracture lines, and (2) evaluate associations between acetabular damage and functional outcomes following fracture. Subchondral bone intensity maps were created for 24 patients with unilateral acetabular fractures. Measures of crack length and density differences between corresponding regions in the fractured acetabuli, normalized by the unfractured side, were generated from preoperative CT images. Damage measures were compared to quality of life survey data collected for each patient at least 2 years post-injury (Musculoskeletal Functional Assessment [MFA] and Short Form-36 [SF-36], with specific focus on parameters that best describe patients' physical health). CT image quantification of initial damage to acetabular subchondral bone was associated with functional outcome post-injury. In general, damage as quantified through differences in density in the superior dome region (zones 8 and 12) and the central anterior region of the acetabulum (zone 3) were found to be the strongest significant predictors of functional outcome (adjusted R(2) = 0.3-0.45, p < 0.05). Damage to the superior dome was predictive of worse functional outcome whereas damage to the central anterior region indicated a better functional outcome. Once automated, this approach may form a basis to score acetabular fractures toward improving clinical prognoses.

Survey of terminology used for the intraoperative direction of C-arm fluoroscopy

BACKGROUND

Orthopedic surgeons depend on the intraoperative use of fluoroscopy to facilitate procedures across all subspecialties. The versatility of the C-arm fluoroscope allows acquisition of nearly any radiographic view. This versatility, however, creates the opportunity for difficulty in communication between surgeon and radiation technologist. Poor communication leads to delays, frustration and increased exposure to ionizing radiation. There is currently no standard terminology employed by surgeons and technologists with regards to direction of the fluoroscope.

METHODS

The investigation consisted of a web-based survey in 2 parts. Part 1 was administered to the membership of the Canadian Orthopedic Association, part 2 to the membership of the Canadian Association of Medical Radiation Technologists. The survey consisted of open-ended or multiple-choice questions examining experience with the C-arm fluoroscope and the terminology preferred by both orthopedic surgeons and radiation technologists.

RESULTS

The survey revealed tremendous inconsistency in language used by orthopedic surgeons and radiation technologists. It also revealed that many radiation technologists were inexperienced in operating the fluoroscope.

CONCLUSION

Adoption of a common language has been demonstrated to increase efficiency in performing defined tasks with the fluoroscope. We offer a potential system to facilitate communication based on current terminology used among Canadian orthopedic surgeons and radiation technologists.

The osteoporotic acetabular fracture

Fractures of the acetabulum are some of the most challenging fractures that face orthopedic surgeons. In geriatric patients, these challenges are enhanced by the complexity of fracture patterns, the poor biomechanical characteristics of osteoporotic bone, and the comorbidities present in this population. Nonsurgical management is preferable when the fracture is stable enough to allow mobilization, and healing in a functional position can be expected. When significant displacement and/or hip instability are present, operative management is preferred in most patients, which may include open reduction and internal fixation with or without total hip arthroplasty.

Functional and anatomic orientation of the femoral head

BACKGROUND

Femoral neck geometry directly affects load transmission through the hip. Orientations may be described anatomically or using functional definitions that consider load transmission.

QUESTIONS/PURPOSES

This study introduces and applies a new method for characterizing functional femoral orientation based on the distribution of subchondral bone density in the femoral head and compares it with orientation measures generated via established anatomic landmark-based methods. Both orientation methods then are used to characterize side-to-side symmetry of orientation and differences between men and women within the population.

PATIENTS AND METHODS

A retrospective review of CT imaging data from 28 patients was performed. Anatomic orientation was determined using established two-dimensional and three-dimensional landmarking methods. Subchondral bone density maps were generated and used to define a density-weighted surface normal vector. Orientation angles generated by the three methods were compared, with side-to-side symmetry and differences between genders also investigated.

RESULTS

The three methods measured substantially different angles for anteversion and neck-shaft angle. Weak correlations were found between anatomic and functional orientation measures for neck-shaft angle only.

CONCLUSIONS

Neck-shaft angles calculated using the functional orientation method corresponded well with previous in vivo loading data. An absence of strong correlation between functional and anatomic measures reinforces the concept that bone geometry is not solely responsible for determining loading of the femoral head.

LEVEL OF EVIDENCE

Level II, Diagnostic Studies--Investigating a Diagnostic Test. See the Guidelines for Authors for a complete description of levels of evidence.

Variability in physician opinions about the indications for knee arthroplasty

To determine how much of variability in physician opinion about the indications for knee arthroplasty is due to inconsistency in individual physicians' opinions. We surveyed 201 orthopedic surgeons, 141 rheumatologists, and 455 family physicians. Physicians were asked how 34 patient characteristics affected their decision to perform or refer for knee arthroplasty. Surgeons and referring physicians agreed on how 4 and 2 of 34 patient characteristics affected their decision about knee arthroplasty, respectively. Half of the variability in opinion among physicians could be accounted for by inconsistency in their individual responses to the survey 6 weeks apart (mean intraclass correlation coefficient = 0.49). Although surgeons and referring physicians vary in their opinion, half of the variability could be attributed to individual physician inconsistency.

Provider volumes and early outcomes of primary total joint replacement in Ontario

BACKGROUND

A relation between provider volume and outcome of total joint replacement (TJR) has not been demonstrated in Canada. Given the recent increase in TJR, changing patient characteristics and small sizes of previous Ontario studies, we reassessed whether adverse outcomes of TJR are related to hospital and surgeon procedure volumes.

METHODS

We included all Ontarians aged 20 years and older who underwent a unilateral elective primary total hip replacement (THR) or total knee replacement (TKR) between April 2000 and March 2004. The main data sources were hospital discharge abstracts and physician billings. We defined provider volume as the average annual number of primary and revision procedures performed by hospitals and surgeons during the study period. We assessed the association between procedure volumes and acute length of hospital stay (ALOS) and between volume and rate of surgical complications during the index admission; death within 90 days of operation; readmission for amputation, fusion or excision within 1 year; and revision arthroplasty within 1 year. We adjusted for age, sex, comorbidity, arthritis type, teaching hospital status and discharge disposition. The analyses of hospital volume were adjusted for surgeon volume and vice versa.

RESULTS

We included 20,290 patients who received THR and 27,217 who received TKR. Patient age, sex and comorbidity were significant predictors of complications and mortality. There were no associations between provider volume and mortality. Findings for other outcomes were mixed. Surgeon procedure volume was related to rates of revision THR but not to rates of revision TKR. Shorter ALOS was associated with male sex, younger age, fewer comorbidities, discharge to a rehabilitation unit or facility and greater surgeon volume.

CONCLUSION

Patient characteristics were significant predictors of complications, ALOS and mortality after primary TJR. Evidence for a relation between provider volume and outcome was limited and inconsistent.

How do validated measures of functional outcome compare with commonly used outcomes in administrative database research for lumbar spinal surgery?

Clinical interpretation of health services research based on administrative databases is limited by the lack of patient-reported functional outcome measures. Reoperation, as a surrogate measure for poor outcome, may be biased by preferences of patients and surgeons and may even be planned a priori. Other available administrative data outcomes, such as postoperative cross sectional imaging (PCSI), may better reflect changes in functional outcome. The purpose was to determine if postoperative events captured from administrative databases, namely reoperation and PCSI, reflect outcomes as derived by validated functional outcome measures (short form 36 scores, Oswestry disability index) for patients who underwent discretionary surgery for specific degenerative conditions of the lumbar spine such as disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis. After reviewing the records of all patients surgically treated for disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis at our institution, we recorded the occurrence of PCSI (MRI or CT-myelograms) and reoperations, as well as demographic, surgical, and functional outcome data. We determined how early (within 6 months) and intermediate (within 18 months) term events (PCSI and reoperations) were associated with changes in intermediate (minimum 1 year) and late (minimum 2 years) term functional outcome, respectively. We further evaluated how early (6–12 months) and intermediate (12–24 months) term changes in functional outcome were associated with the subsequent occurrence of intermediate (12–24 months) and late (beyond 24 months) term adverse events, respectively. From 148 surgically treated patients, we found no significant relationship between the occurrence of PCSI or reoperation and subsequent changes in functional outcome at intermediate or late term. Similarly, earlier changes in functional outcome did not have any significant relationship with subsequent occurrences of adverse events at intermediate or late term. Although it may be tempting to consider administrative database outcome measures as proxies for poor functional outcome, we cannot conclude that a significant relationship exists between the occurrence of PCSI or reoperation and changes in functional outcome.

Mortality and complications following stabilization of femoral metastatic lesions: a population-based study of regional variation and outcome

BACKGROUND: It is considered that patients at risk for spontaneous fracture due to metastatic lesions should undergo surgical stabilization before fracture occurs; however, prophylactic stabilization is associated with surgical morbidity and mortality. We sought to compare pathological fracture fixation versus prophylactic stabilization of diaphyseal femoral lesions for patients with femoral metastases and assess the rate of prophylactic surgery completed in all regions of Ontario. METHODS: Using population data sets, we identified all patients who had undergone femoral stabilization, either for pathological femoral fractures or for prophylactic fixation of femoral metastases before pathological fractures, between 1992 and 1997 in Ontario. We compared the rates of survival, serious medical and surgical complications and length of stay in hospital between the 2 groups. RESULTS: A total of 624 patients underwent surgical stabilization for femoral metastases. The most common sites of primary metastases were the lungs (26%), breasts (16%), kidneys (6%) and prostate (6%); 46% of patients had other or multiple primary metastases. Overall, 37% of lesions were fixed prophylactically, with wide variation by region (17.6%-72.2%). Patients who underwent prophylactic stabilization had better overall survival at all postoperative time points. This held true after adjusting for age, sex, comorbidities and type of cancer (p < 0.001). CONCLUSION: These data demonstrate a survival advantage with prophylactic fixation of metastatic femoral lesions combined with a relatively low perioperative risk excluding concomitant bilateral procedures. Ontario regional rates of prophylactic fixation vary enormously, with most patients not receiving prophylactic treatment.

The who, what and when of surgery for the degenerative lumbar spine: a population-based study of surgeon factors, surgical procedures, recent trends and reoperation rates

BACKGROUND: Degenerative disease of the lumbar spine (DLS) is a common condition for which surgery can be beneficial in selected patients. With recent surgical trends toward more focused subspecialty training, it is unclear how characteristics of the surgical consultant may impact on treatment and reoperations. Our objective was to understand the relations between surgeon factors (who), surgical procedures (what) and recent trends (when) and their influence on reoperations for DLS surgery. METHODS: We performed a longitudinal population-based study using administrative databases including all patients aged 50 years and older who underwent surgery for DLS. We collected data on surgeon characteristics (specialty, volume), index procedures (decompressions, fusions) and reoperations. RESULTS: We identified 6128 patients who underwent surgery for DLS (4200 who had decompressions, 1928 who had fusions). We observed an increasing proportion of fusions over decompressions while the per capita surgeon supply declined. Orthopedic specialty and higher surgical volume were associated with a higher proportion of fusions (p < 0.001). The overall reoperation rate was 10.6%. Reoperations were more frequent in patients who had decompressions than those who had fusions at 2 years (5.4% v. 3.8%, odds ratio 1.4, p < 0.013), but not over the long-term. Long-term survival analysis demonstrated that a lower surgical volume was related to a higher reoperation rate (hazard ratio 1.28, p = 0.038). CONCLUSION: Lumbar spinal fusion rates for DLS have been increasing in Ontario. There is wide variation in surgical procedures between specialty and volume: namely high-volume and orthopedic surgeons have higer fusion rates than other surgeons. We observed better long-term survival among patients of high-volume surgeons. Referring physicians should be aware that the choice of surgical consultant may influence patients' treatments and outcomes. With increasing rates of spinal surgery, the efficacy and cost benefit of current surgical options require ongoing study.

Patients' gender affected physicians' clinical decisions when presented with standardized patients but not for matching paper patients

OBJECTIVE

To compare physicians' treatment and referral decisions for total knee arthroplasty (TKA) for standardized patients with matching paper patients.

STUDY DESIGN AND SETTING

Sixty-seven physicians (38 family physicians and 29 orthopedic surgeons) performed blinded assessments of two standardized patients (one man and one woman) with moderate knee osteoarthritis and otherwise identical clinical scenarios differing only in gender, and consented to including their data. Standardized patients recorded physicians' recommendations (yes/no) to refer for, or perform, TKA. Sixty physicians provided their treatment recommendations to matching paper patients.

RESULTS

Recommendation rates for both the male and the female standardized patients (67% and 32%, respectively) were lower compared with the matching paper patients (80% and 67%, respectively). Physicians were more likely to recommend TKA to a man than to a woman when presented with standardized patients (odds ratio, 4.2; 95% confidence interval [CI]=2.4-7.3; P<0.001). In contrast, patients' gender did not affect the same physicians' recommendations regarding referral for, or performing, TKA for the matching paper patients (odds ratio, 2.0; 95% CI=0.9-4.6; P=0.101).

CONCLUSION

Unlike their treatment recommendations for standardized patients, the same physicians' treatment and referral decisions for paper patients were not influenced by patients' gender, suggesting that paper patients are not a sensitive method of assessing physician bias.

Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review

BACKGROUND

Total joint arthroplasty is a highly efficacious and cost-effective procedure for moderate to severe arthritis in the hip and knee. Although patient characteristics are considered to be important determinants of who receives total joint arthroplasty, no systematic review has addressed how they affect the outcomes of total joint arthroplasty. This study addresses how patient characteristics influence the outcomes of hip and knee arthroplasty in patients with osteoarthritis.

METHODS

We searched 4 bibliographic databases (MEDLINE 1980-2001, CINAHL 1982-2001, EMBASE 1980-2001, HealthStar 1998-1999) for studies involving more than 500 patients with osteoarthritis and 1 or more of the following outcomes after total joint arthroplasty: pain, physical function, postoperative complications (short-and long-term) and time to revision. Prognostic patient characteristics of interest included age, sex, race, body weight, socioeconomic status and work status.

RESULTS

Sixty-four of 14,276 studies were eligible for inclusion and had extractable data. Younger age (variably defined) and male sex increased the risk of revision 3-fold to 5-fold for hip and knee arthroplasty. The influence of weight on the risk of revision was contradictory. Mortality was greatest in the oldest age group and among men. Function for older patients was worse after hip arthroplasty (particularly in women). Function after knee arthroplasty was worse for obese patients.

CONCLUSION

Although further research is required, our findings suggest that, after total joint arthroplasty, younger age and male sex are associated with increased risk of revision, older age and male sex are associated with increased risk of mortality, older age is related to worse function (particularly among women), and age and sex do not influence the outcome of pain. Despite these findings, all subgroups derived benefit from total joint arthroplasty, suggesting that surgeons should not restrict access to these procedures based on patient characteristics. In addition, future research needs to provide standardized measures of outcomes.

Interobserver reliability of the young-burgess and tile classification systems for fractures of the pelvic ring

OBJECTIVES

The purpose of this study was to measure interobserver reliability of 2 classification systems of pelvic ring fractures and to determine whether computed tomography (CT) improves reliability. The reliability of several radiographic findings was also tested.

METHODS

Thirty patients taken from a database at a Level I trauma facility were reviewed. For each patient, 3 radiographs (AP pelvis, inlet, and outlet) and CT scans were available. Six different reviewers (pelvic and acetabular specialist, orthopaedic traumatologist, or orthopaedic trainee) classified the injury according to Young-Burgess and Tile classification systems after reviewing plain radiographs and then after CT scans. The Kappa coefficient was used to determine interobserver reliability of these classification systems before and after CT scan.

RESULTS

For plain radiographs, overall Kappa values for the Young-Burgess and Tile classification systems were 0.72 and 0.30, respectively. For CT scan and plain radiographs, the overall Kappa values for the Young-Burgess and Tile classification systems were 0.63 and 0.33, respectively. The pelvis/acetabular surgeons demonstrated the highest level of agreement using both classification systems. For individual questions, the addition of CT did significantly improve reviewer interpretation of fracture stability. The pre-CT and post-CT Kappa values for fracture stability were 0.59 and 0.93, respectively.

CONCLUSIONS

The CT scan can improve the reliability of assessment of pelvic stability because of its ability to identify anatomical features of injury. The Young-Burgess system may be optimal for the learning surgeon. The Tile classification system is more beneficial for specialists in pelvic and acetabular surgery.

The effect of patients' sex on physicians' recommendations for total knee arthroplasty

BACKGROUND

The underuse of total joint arthroplasty in appropriate candidates is more than 3 times greater among women than among men. When surveyed, physicians report that the patient's sex has no effect on their decision-making; however, what occurs in clinical practice may be different. The purpose of our study was to determine whether patients' sex affects physicians' decisions to refer a patient for, or to perform, total knee arthroplasty.

METHODS

Seventy-one physicians (38 family physicians and 33 orthopedic surgeons) in Ontario performed blinded assessments of 2 standardized patients (1 man and 1 woman) with moderate knee osteoarthritis who differed only by sex. The standardized patients recorded the physicians' final recommendations about total knee arthroplasty. Four surgeons did not consent to the inclusion of their data. After detecting an overall main effect, we tested for an interaction with physician type (family physician v. orthopedic surgeon). We used a binary logistic regression analysis with a generalized estimating equation approach to assess the effect of patients' sex on physicians' recommendations for total knee arthroplasty.

RESULTS

In total, 42% of physicians recommended total knee arthroplasty to the male but not the female standardized patient, and 8% of physicians recommended total knee arthroplasty to the female but not the male standardized patient (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.4-7.3, p < 0.001; risk ratio [RR] 2.1, 95% CI 1.5-2.8, p < 0.001). The odds of an orthopedic surgeon recommending total knee arthroplasty to a male patient was 22 times (95% CI 6.4-76.0, p < 0.001) that for a female patient. The odds of a family physician recommending total knee arthroplasty to a male patient was 2 times (95% CI 1.04-4.71, p = 0.04) that for a female patient.

INTERPRETATION

Physicians were more likely to recommend total knee arthroplasty to a male patient than to a female patient, suggesting that gender bias may contribute to the sex-based disparity in the rates of use of total knee arthroplasty.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction

OBJECTIVES

A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.

METHODS

Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.

RESULTS

CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.

CONCLUSION

This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Factors associated with outcome after subtalar arthrodesis

OBJECTIVES

To evaluate radiographic and functional outcomes after subtalar arthrodesis and to identify patient factors associated with poor outcome.

DESIGN

Retrospective study.

SETTING

Two academic hospitals.

PATIENTS

Eighty-eight patients with primary or secondary osteoarthritis treated between 1995 and 2002.

INTERVENTION

Primary subtalar arthrodesis.

MAIN OUTCOME MEASUREMENTS

Radiographic outcome was assessed by determining union rates. Functional outcome was assessed through self-administered questionnaires (Short Form-36, Short Musculoskeletal Function Assessment, and the AAOS Foot and Ankle Instrument).

RESULTS

After adjusting for age and sex smokers were 3.8 times more likely to go on to nonunion than nonsmokers (P < 0.05). As patients aged, there was a higher likelihood of nonunion if they also smoked (P < 0.05). Of patients undergoing subtalar bone block distraction arthrodesis 95% went on to union compared with 65% of patients treated with an in situ subtalar arthrodesis without bone graft (P < 0.05). There was a trend for higher rates of union if a bone graft was used among patients treated with an in situ subtalar arthrodesis. Diabetic patients were 18.7 times more likely to have a malunion (P < 0.05). As a group, patients who have undergone subtalar arthrodesis can expect significantly worse functional outcomes compared with the Canadian and American normative populations. The poorest functional outcomes were observed among patients with diabetes. A trend for poorer outcome in bodily pain and general health (Short Form-36) was seen in workers' compensation patients.

CONCLUSIONS

Certain patient variables are associated with poorer outcomes after subtalar fusion. The results of this study will enable surgeons to provide better information to patients in preoperative discussions with respect to patient expectations, outcomes, and the success of surgery.

Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.

A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires

OBJECTIVES

To compare closed reduction and casting with closed reduction and external fixation with optional K-wire fixation for distal radius fractures with metaphyseal displacement but without joint incongruity.

DESIGN

Prospective study.

SETTING

Multicenter study at 3 University teaching hospitals.

PATIENTS/PARTICIPANTS

A total of 113 skeletally mature patients with distal radius fractures with metaphyseal displacement, but without joint incongruity, were randomized to receive 1 of 2 standardized treatment protocols. Patients were evaluated at 6 weeks, 6 months, 1 year, and 2 years.

INTERVENTION

Closed reduction and casting (n = 59) or closed reduction and external fixation (n = 54).

MAIN OUTCOME MEASUREMENTS

Upper extremity function was measured using upper extremity MFA domain scores, overall Jebsen Taylor scores, and pinch and grip strength tests. Global function and pain were measured using the SF-36. Radiographic evaluation and range of motion were documented.

RESULTS

Upper extremity MFA scores, Jebsen Taylor scores, SF-36 bodily pain scores, and grip strength improved significantly during the first year for all patients. By 2 years, mean Jebsen Taylor scores and SF 36 bodily pain scores for patients in both groups were similar to scores for normal age- and gender-matched population controls. At all points, there was a trend for better function in the external fixation; however, this did not reach statistical significance. There was a trend for better length and palmar tilt restoration with external fixation.

CONCLUSIONS

For distal radius fractures with metaphyseal displacement but with a congruous joint, there exists a trend for better functional, clinical, and radiographic outcomes when treated by immediate external fixation and optional K-wire fixation.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures

BACKGROUND

Displaced fractures of the midpart of the clavicular shaft are generally treated nonoperatively, and few functional deficits have been reported. Whereas prior investigators have presented radiographic and surgeon-based outcomes, we used a patient-based outcome questionnaire and objective muscle-strength testing to evaluate a series of patients who had received nonoperative care for a displaced midshaft fracture of the clavicle.

METHODS

We identified thirty patients (twenty-two men and eight women with a mean age of thirty-seven years) who had sustained a displaced midshaft fracture of the clavicle. All patients were treated nonoperatively. At a mean of fifty-five months, and a minimum of twelve months, outcomes were measured with the Constant shoulder score and the DASH (Disabilities of the Arm, Shoulder and Hand) patient questionnaire. In addition, objective shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control.

RESULTS

The range of motion was well maintained, with flexion averaging 170 degrees +/- 20 degrees and abduction averaging 165 degrees +/- 25 degrees . Compared with the strength of the uninjured shoulder, the strength of the injured shoulder was reduced to 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all values). The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.

CONCLUSIONS

Traditionally, good results with minimal functional deficits have been reported following nonoperative treatment of clavicular fractures. However, surgeon-based methods of evaluation may be insensitive to loss of muscle strength. We detected residual deficits in shoulder strength and endurance in this patient population, which may be related to the significant level of dysfunction detected by the patient-based outcome measures.

Bilateral total knee arthroplasty--staged or simultaneous? Ontario's orthopedic surgeons reply

BACKGROUND

Total knee replacement is now the most common joint replacement procedure performed in Ontario, and many patients require bilateral replacement. However, whether bilateral total knee arthroplasty (TKA) should be staged or simultaneous is hotly debated. To determine the current common operative practices of orthopedic surgeons in Ontario, we carried out a province-wide survey.

METHODS

Orthopedic surgeons from Ontario listed in the 1999 Canadian Medical Directory or the membership list of the Canadian Orthopaedic Association were sent questionnaires, asking about their practice in the timing of bilateral TKA, tourniquet use, type of guide and use of techniques to minimize fat embolization.

RESULTS

Of the 416 surveys mailed, 219 (53%) surgeons responded. The majority responded that they perform staged bilateral TKA (28% 3-mo interval and 37% 6-mo interval). Simultaneous TKA with 2 teams was the least performed procedure (2%). When performing bilateral TKA, 95% of surgeons use an intramedullary femoral alignment guide, 78% utilize an over-reamed entry hole and 53% suction the canal before inserting the guide rod. With respect to the tibia, 32% use an intramedullary guide, 60% over-ream the entry hole and 60% suction the entry hole; 22% of surgeons stated that they had never considered over-reaming or suctioning the canal to minimize fat embolization.

CONCLUSIONS

There is no consensus regarding the timing of bilateral TKA in Ontario. Furthermore, many surgeons are not overdrilling or suctioning the femoral canal despite evidence in the literature that overdrilling may be beneficial in decreasing fat embolization. Further research is required to compare the risk of complications of bilateral TKA after staged versus simultaneous TKA.