Treatment rates for osteoporosis after a major osteoporotic fracture are unacceptably low. We evaluate the effectiveness of an ortho-geriatric team (OGT) in initiating pharmacologic therapy for osteoporosis post-hip fracture. The OGT was able to achieve a higher treatment rate for patients post-hip fracture in comparison to usual care provided by the primary care hospitalist. Potential reasons for delaying or not proceeding with drug therapy include patient concern regarding potential rare side effects of antiresorptive therapy including osteonecrosis of the jaw and atypical femoral fracture. These events however are rare, and in this study, only 3% of hip fractures were atypical femoral fractures.INTRODUCTION:Currently, a significant care gap for osteoporosis therapy exists post-hip fracture despite advances in pharmacologic therapy. We evaluate the effectiveness of the OGT at the Oakville Trafalgar Memorial Hospital (OTMH), Ontario, Canada, in reducing the care gap and initiating pharmacologic therapy in hip fracture patients prior to hospital discharge. We also evaluated the incidence of atypical femoral fracture (AFF) separately.METHODS:A retrospective chart review of patients 59 years and older with a hip fracture admitted to OTMH from January 1, 2016, to February 1, 2017, was conducted. The primary outcome was the proportion of hip fracture patients discharged from the hospital with appropriate treatment for their underlying osteoporosis. A sub-analysis was completed reporting the incidence of AFF among older adults.RESULTS:A total of 197 patients with a hip fracture were identified, 134/197 (68%) patients were seen by the OGT, 98/134 (73%) of these patients were started on pharmacologic therapy prior to discharge, and 120/134 (89%) of patients seen by the OGT were on treatment within 3 months of discharge following assessment in the complex osteoporosis clinic. Sixty-three patients of the 197 (63/197) (32%) of the hip fracture patients were seen by a hospitalist, and treatment rates prior to discharge were 5%. Only 6/197 patients had experienced an AFF during the study period, and all patients with an atypical femoral fracture had been on long-term bisphosphonate therapy. All of the patients with an AFF had thigh or groin pain for several weeks to months prior to the development of the atypical femoral fracture, providing an opportunity to stop therapy and possibly prevent the development of a complete AFF.CONCLUSION:The OGT was able to initiate anti-osteoporosis therapy in significantly more patients in comparison to usual care, and higher treatment rates are possible with an OGT.

Objectives: The FAITH trial evaluated effects of sliding hip screws versus cancellous screws in femoral neck fracture patients. Using FAITH trial data, we quantified changes in living status, use of aids, and investigated factors associated with living and walking independently 12 months after fracture. Methods: We conducted a descriptive analysis to quantify patients' changes in living status, use of aids, and used multivariable Cox regression analyses to determine factors associated with living and walking independently after fracture. Results: Of patients who lived independently before hip fracture, 3.07% (50–80 years old) and 19.81% (>80 years old) were institutionalized 12 months after injury. Of patients who were walking independently before injury, 33.62% (50–80 years old) and 69.34% (>80 years old) required a walking aid 12 months after injury. Factors associated with higher chances of living independently included the following: being between 50 and 80 years, having a class I American Society of Anesthesiologists classification, not using a walking aid before fracture, being a nonsmoker or former smoker, and having an acceptable quality of implant placement. Factors associated with higher chances of walking without an aid included the following: being between 50 and 80 years, having a class I American Society of Anesthesiologists classification, living independently before fracture, being a nonsmoker or former smoker, having an undisplaced fracture, and not requiring revision surgery. Conclusions: Femoral neck fracture patients suffer great losses of independence. Identifying factors associated with living and walking independently after hip fracture may help surgeons better identify which patients are at risk and optimize care of patients with this injury. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

BackgroundWhile serum interleukin-6 (IL-6) clearly has been established as a marker of physiologic stress, the validity of IL-6 as a reliable measure of the degree of trauma or stress suffered by an individual with total knee replacement (TKA) remains in question. We hypothesized that if serum IL-6 is a marker of surgical stress, then we would observe marked increases in IL-6 levels in sequential bilateral TKA as compared with unilateral TKA.MethodsThe study design was a single-surgeon prospective case-control pilot study of sequential bilateral TKA cases and unilateral TKA controls to assess changes in serum IL-6 levels preoperatively, during, at wound closure, and up to 48 hours postoperatively. IL-6 levels were analyzed using a one-way mixed models analysis of variance.ResultsEleven patients with unilateral and 12 with bilateral TKA comprised the study sample. IL-6 levels at peak (24 hours postoperatively) for the unilateral control group was 12 times higher compared with baseline (4.6 pg/mL compared with 55.0 pg/mL), while the bilateral TKA group saw a 116-fold increase in IL-6 from baseline to peak at 12 hours postoperatively (2.9 pg/mL compared with 335.0 pg/mL). At "peak,'' IL-6 was 6.1 times higher for the bilateral group compared with the unilateral group.ConclusionsThis pilot study supports the notion that sequential bilateral TKA produces a far greater surgical stress, as measured by IL-6. Careful patient selection, counseling, and consideration of staging procedures are advised.

BACKGROUND The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR. METHODS We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management. RESULTS The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice. CONCLUSION Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.

Controversy exists surrounding best practice for antibiotic prophylaxis in TJR. Practicing orthopedic surgeons performing TJR in Canada were surveyed to inform regarding the most common antibiotic prophylaxis practice. Cross-sectional survey of five hundred and ninety practicing Canadian orthopaedic surgeons was conducted. Three orthopaedic surgeons, and one infectious disease specialist established face and content validity of the survey. The survey was mailed to surgeons, and re-mailed to non-responders at twelve-weeks. Survey included questions pertaining to prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision setting, as well as postoperative wound drainage investigation and management. Response rate after two mail-outs was 410/590 (69.5%). 96.6% indicated routine use of systemic prophylactic antibiotics for uncomplicated primary TJR. Cefazolin was most commonly prescribed (97.3 %), with 1gm Cefazolin the most common dosage (70.2%). Vancomycin was prescribed 26% of the time as first line. 48.5% administer the antibiotic in the operating suite, and 90% administer within two hundred TJR’s per year, and 40/410 (9.8%) were categorised as low volume performing Opinions vary widely amongst surgeons in Canada, illustrating the controversy in what constitutes ‘best practice’. Despite available published data, a large proportion of Canadian surgeons may fall short in meeting optimal standards of care in some domains such as the dose prescribed and timing of administration. This survey also illustrates the lack of available information to guide current management of postoperative wound drainage in the face of shorter patient hospital stays. Much work is needed in this area to determine risks and benefits of these costly tests and interventions in treating arthroplasty patients.

Objective: Given the continued debate regarding syndesmotic screw fixation, we reviewed our institution's series of ankle syndesmotic screw insertions: 1) to examine technical aspects of syndesmotic screw fixation; and 2) to identify predictors of function and quality of life utilizing validated instruments. Design: Retrospective observational study (level IV). Setting: Three university hospitals. Patients and Methods: All patients with ankle injuries who received syndesmotic screw fixation at 3 university-affiliated hospitals from 1998 to 2001. A combined hospital database for all 3 university affiliated hospitals was searched to identify all ankle fractures. Potentially eligible patients' charts were hand searched to determine the use of syndesmotic screw fixation. Radiographs from each patient were assessed for final eligibility for study inclusion. Baseline demographic information, fracture type (Lauge-Hansen, AO Weber), radiographic measurements of syndesmotic reduction, type of implants (number of screws, number of cortices, screw size), and screw removal at follow-up were determined. All radiographs were standardized for magnification. Patients also reported return to work, a visual analogue ankle pain score, and completed 2 functional outcomes instruments (Short Musculoskeletal Functional Assessment Index, Olerud and Molander Scale). Main Outcomes: Return to work, a visual analogue ankle pain score, and 3 functional outcomes instruments (Short Musculoskeletal Functional Assessment Index, Olerud and Molander Scale). Results: Of 425 ankle fractures treated, 51 fractures had syndesmotic screw fixation. Patients were often males (67%), mean age 40.0 ± 18.0 years, with sedentary occupations (88%), and twisting injuries (80%). Seventy percent of injuries were pronation external rotation injuries, and 30% were supination external rotation injuries. The ankle was dislocated in 45% of cases. The most common constructs for fixation included lateral plates with syndesmotic screws (45%). The majority of constructs included a single 3.5-mm cortical screw through 3 cortices of bone. Based upon postoperative x-rays, 16% of syndesmoses were not reduced. Additionally, 8 patients were deemed have inappropriate/lack of indications for syndesmotic screw insertion. At final follow-up (N = 39 patients, mean 18.1 months), patients achieved good function and quality of life (mean scores: Short Musculoskeletal Functional Assessment functional index = 11.4 ± 10.6, Short Musculoskeletal Functional Assessment bother index = 13.5 ± 13.1, Olerud and Molander = 74.1 ± 23.4, visual analogue pain scale = 1.7 ± 1.9). The only significant predictor of functional outcome was reduction of the syndesmosis (P = 0.04). This variable alone accounted for 18% of the variation in Short Musculoskeletal Functional Assessment Index physical function scores and 15% of the variance in the Olerud and Molander (running subscale) outcome measure. Conclusions/Significance: Our findings suggest: 1) technical aspects of syndesmotic screw fixation vary between surgeons; 2) 16% of syndesmotic screws may have been unnecessary; and 3) despite variability in technique and indications, anatomic reduction of syndesmosis was significantly associated with improved Short Musculoskeletal Functional Assessment Index functional outcome. Larger, prospective studies are needed to further explore our findings.

BACKGROUND:The purpose of this research was to compare associated injuries and mortality in multiply injured patients with scapular fractures with those without scapular fractures. METHODS:A prospectively collected database of multiply injured motor vehicle occupants with an Injury Severity Score >12 admitted to a level I regional trauma center during from January 1, 1996, to December 31, 2001, was reviewed to assess skeletal and organ injuries associated with a scapular fracture. RESULTS:Of 2,538 motor vehicle occupants, 94 occupants with concomitant scapular fractures and 2,444 occupants without scapular fractures revealed that 76.6% of motor vehicle occupants who sustained scapular fractures were males with a mean age of 44.3 years (SD=18.9). The presence of a scapular fracture reduced the risk of mortality by 44% (95%CI: 1-75%). Patients with scapular fractures had a greater proportion of flail chest injuries [relative risk (RR), 8.8; p < 0.001], clavicle fractures (RR, 4.5; p < 0.001), rib fractures (RR, 3.1; p < 0.01), spine fractures (RR, 2.7; p < 0.001), and tibia and fibular fractures (RR, 1.7; p < 0.025). The presence of a chest injury, either a pneumothorax (RR, 3.7; p < 0.001) or a pulmonary contusion (RR, 3.5; p < 0.001), was significantly more likely in patients with scapular fractures than control patients. Injuries to the spleen (RR, 2.4; p < 0.01) and liver (RR, 2.2; p < 0.025) were also significantly more common in patients with scapular fractures when compared with those without them. CONCLUSIONS:In an observational study of multiply injured trauma patients from motor vehicle crashes, we report the following: (1) scapular fractures occur 3.7% of the time; (2) the presence of a scapular fracture was associated with a lower mortality; and (3) scapular fractures should alert healthcare personnel to the presence of other injuries, such as chest injuries, clavicle fractures, rib fractures, spine fractures, tibial fractures, and spleen and liver injuries. Our findings should be interpreted cautiously, because the mechanism of the association between scapular fractures and mortality remains unclear.

BACKGROUND Given the limited evidence to support the technical aspects of screw placement for treatment of femoral neck fractures, we conducted an observational study to evaluate demographic and radiographic variables associated with fixation failure. METHODS Eligible patients with femoral neck fractures were treated with multiple cannulated screws across three academic centers during a 6-year period. The following variables were evaluated for their predictive value for fixation failure: age, gender, fracture type, presence of comminution, total number of screws, the absence of a washer, the screw configuration, reduction quality, the distance of the most inferior screw to the inferior neck, and screw alignment. Variables were evaluated separately and in a multivariable regression model. RESULTS Eighty patients were included in the study. The overall failure rate was 30%. We identified four variables associated with fixation failure. These included the lack of washers (odds ratio [OR], 11.2; p = 0.03), imperfect quality of reduction (OR, 9.7; p < 0.01), age greater than 75 years (OR, 5.1; p = 0.04), and displaced versus undisplaced fracture type (OR, 3.8; p < 0.01). These four variables accounted for 43% of the variability in fixation failure (R(2) = 0.43). All other variables including the distance of the most inferior screw to the inferior/medial neck were found to be not significant. CONCLUSION This study confirms previous findings in the literature that increased age, a displaced fracture type, and poor reduction increase the risk of fixation failure. Contradictory to current belief, there was no significant association between the distance of the inferior screw to the inferior/medial femoral neck cortex and fixation failure. A novel finding of the present study is that the use of washers significantly decreases the risk of fixation failure.

*Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canadá; and †Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canadá

*Division of Orthopaedic Surgery, McMaster University Hamilton, Ontario, Canada; and †Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada