OBJECTIVE:To examine musculoskeletal (MSK) knowledge among physicians who completed different MSK curricula during their undergraduate medical training. DESIGN:A multisite survey-based investigation was completed across three Canadian medical programs. Physicians who graduated from these programs over a 6-year period were invited to complete a standardized musculoskeletal examination. RESULTS:A total of 327 physicians (15.9% response rate) completed the examination, achieving a mean score of 74.6% (±9.6, range 50 - 100%). Despite high levels of knowledge, the mean self-reported confidence among respondents was only 2.73/5.0 with no significant difference between programs. While physicians in musculoskeletal specialties performed significantly better than other specialties on the examination (P<0.05), the impact of MSK electives during clerkship varied with elective participation resulting in significantly higher knowledge of graduates from only one of the programs (P<0.05). Family physicians who completed their training at two of the programs performed significantly better compared to non-musculoskeletal specialists (P<0.05). CONCLUSION:Despite the heterogeneity within the musculoskeletal training environment across medical programs in Canada, no significant differences in MSK knowledge were detected among physicians. Despite higher MSK examination scores than previous literature, physicians reported low confidence in managing MSK conditions in the clinical setting.

Extracellular vesicles (EVs) are nano-sized membrane-bound structures thought to be secreted by all cells and increasingly recognized as key mediators of intercellular communication. Established EV isolation protocols for bodily fluids-primarily focus on blood with limited insights into methods optimized for EVs from other hematopoietic regions. In this study, we present a novel protocol for the isolation and enrichment of EVs from human trabecular bone and bone marrow. This method employs a two-step purification strategy, combining iodixanol density cushion (IDC) ultracentrifugation with size exclusion chromatography (SEC), and enables EV recovery from fresh tissue hours after collection. Importantly, this approach facilitates the enrichment of bone-derived EVs without the need for enzymatic digestion or long-term culture, preserving native EV populations. This protocol offers a valuable tool for researchers investigating EVs derived from the diverse cellular constituents of the bone microenvironment. ### Competing Interest Statement The authors have declared no competing interest. Canadian Institutes of Health Research, https://ror.org/01gavpb45, 394568 Terry Fox Research Institute, https://ror.org/00mtf6c40, 1133

BACKGROUND:The value of gender representation has been increasingly recognised in medicine, yet women represent only 13.6% of orthopaedic surgeons in Canada. The primary objective of this study was to determine barriers identified by medical students considering pursuing a career in orthopaedic surgery. The secondary objective was to assess for gender-based differences in barriers identified by medical students. METHODS:A cross-sectional mixed-methods survey was distributed to final-year students at a Canadian medical school. Descriptive analyses were calculated for the study population and gender subgroups. To compare responses between gender subgroups, chi-square or Fisher's exact tests were employed for binary data, and non-parametric Mann-Whitney U tests for ordinal data. Open-text responses were reviewed for descriptions of students' experiences in orthopaedics. RESULTS:Sixty-four medical students participated, representing a response rate of 59.3%. Male culture and the need for physical strength were identified as strong barriers to pursuing a career in orthopaedics. Additionally, women reported less exposure (p = 0.003), disproportionate constraints (i.e., scrutiny of performance based on gender, p = 0.001), less mentorship (p = 0.028), more concerns about verbal (p < 0.001) and sexual abuse (p = 0.013), and higher rates of direct discouragement from pursuing orthopaedics than men (p = 0.035). Open-text responses indicated that orthopaedics was not considered welcoming to all medical students. CONCLUSIONS:This study is the first to characterise medical student perceptions of barriers to gender equity in orthopaedic surgery in Canada. Fostering a more equitable environment will necessitate a paradigm shift in the educational framework toward orthopaedic surgery.

The Canadian Undergraduate Surgical Education Committee (CUSEC) undertook a project to address variance in undergraduate surgical learning objectives among Canada's medical schools. Its aim was to compile a reasonable set of national undergraduate surgical learning objectives (NUSLOs) for all medical undergraduates and map them to the Medical Council of Canada (MCC) objectives. In phase 1, CUSEC invited Canada's 10 surgical specialty societies or associations to identify discipline-specific lists of undergraduate surgical learning objectives deemed essential for all Canada's medical students to achieve by the time of graduation. In phase 2, 8 medical students and 7 CUSEC faculty from 6 Canadian universities mapped each individual NUSLO to the corresponding MCC objectives, then to primary and secondary MCC objectives. By 2023, all 10 surgical specialty societies had derived, ratified, and submitted their discipline-specific NUSLOs, for a total of 72 major objectives, some of which had sub-objectives. All phase 1 NUSLOs were mapped to corresponding MCC objectives, with each NUSLO mapping to an average of 18 MCC objectives. Each NUSLO was then tiered to 1-2 primary MCC objectives. The NUSLOs and the NUSLO-MCC maps, now publicly posted on the CUSEC website, may serve as a foundational reference for students and teachers. They are a means by which Canada's medical schools can customize, standardize, and revise their undergraduate surgical curricula.

Women have consistently comprised more than half of Canadian medical students since the 1990s, however, they represent only 13.6% of orthopaedic surgeons in Canada. To promote gender equity in the specialty, it is essential to understand and address the factors negatively affecting female medical students considering a career in orthopaedic surgery. The primary objective of this study was to determine the barriers identified by medical students when considering pursuing a career in orthopaedic surgery. The secondary objective was to assess whether there are gender-based differences in factors affecting medical students considering pursuing a career in orthopaedic surgery. A cross-sectional mixed-methods survey was distributed to all final-year students at a Canadian medical school. Quantitative survey responses were assessed using a five-point Likert scale or closed-ended questions. Descriptive analyses, including means and standard deviations, were calculated for the entire study population and gender subgroups. Chi-square or Fisher's exact tests were employed for binary data, and non-parametric Mann-Whitney U tests for ordinal data, to compare responses between gender subgroups. Illustrative excerpts from open-text responses were presented. Sixty-four medical students participated, representing a response rate of 59.3%. Forty-four respondents identified as women and 20 as men. Male privilege and physical strength were identified as strong barriers to pursuing a career in orthopaedic surgery by both women and the entire study population. Women additionally reported less exposure (p=0.003), less mentorship (p=0.028), disproportionate constraints (performance scrutinized differently, p=0.001), and concern about hostility (verbal abuse, p In this study, male privilege and physical strength were identified as strong barriers to pursuing a career in orthopaedic surgery. Lack of exposure, insufficient support, disproportionate constraints, and hostility were additional factors which were found to differentially affect women and men considering pursuing a career in orthopaedic surgery. These barriers are rooted in a culture of gender bias and stereotypes, perpetuating the underrepresentation of women in orthopaedic surgery. Breaking this cycle with require concerted, deliberate efforts at every step along the pipeline to orthopaedic surgery, from early exposure in medical school training to the creation of sustainable mentorship programs, to bias training for trainees and staff. Recognizing that gender diversity is just one aspect of promoting overall diversity, comprehensive interventions that address intersecting identities are necessary to foster true inclusivity and equity within the orthopaedic workforce.

In 2022, the Ontario Ministry of Health recommended preoperative nasal mupirocin and chlorhexidine body wash for Staphylococcus aureus decolonization. This 2025 cross-sectional study of 61 Ontario hospitals showed heterogeneity in decolonization protocols prior to hip and knee arthroplasty. Only 6.6% of hospitals indicated both recommended measures, highlighting an evidence-practice gap.

ObjectiveThe aim of the study is to document the current state of musculoskeletal (MSK) medicine education across nationally accredited undergraduate medical programs.DesignA cross-sectional survey design was used to gather curricular data on the following three musculoskeletal themes: (1) anatomy education, (2) preclinical education, and (3) clerkship education.ResultsThe survey had a 100% response rate with all 14 English-language medical schools in Canada responding. The mean time spent teaching musculoskeletal anatomy was 29.8 hrs (SD +/- 13.7, range = 12-60), with all but one program using some form of cadaveric-based instruction. Musculoskeletal preclinical curricula averaged 58.0 hrs (SD +/- 53.4, range = 6-204), with didactic lectures, case-based learning, and small group tutorials being the most common modes of instruction. Curricular content varied greatly, with only 25% of "core or must-know" musculoskeletal topics being covered in detail by all programs. Musculoskeletal training in clerkship was required by only 50% of programs, most commonly being 2 wks in duration.ConclusionsResults document the large variability and curricular inadequacies that exist in musculoskeletal education across nationally accredited allopathic programs and highlight the need for the identification and implementation of more consistent musculoskeletal curricular content and educational standards by all nationally accredited medical programs.

BACKGROUND:Our institution simultaneously transitioned all postgraduate specialty training programs to competency-based medical education (CBME) curricula. We explored experiences of CBME-trained residents graduating from five-year programs to inform the continued evolution of CBME in Canada. METHODS:We utilized qualitative description to explore residents' experiences and inform continued CBME improvement. Data were collected from fifteen residents from various specialties through focus groups, interviews, and written responses. The data were analyzed inductively, using conventional content analysis. RESULTS:We identified five overarching themes. Three themes provided insight into residents' experiences with CBME, describing discrepancies between the intentions of CBME and how it was enacted, challenges with implementation, and variation in residents' experiences. Two themes - adaptations and recommendations - could inform meaningful refinements for CBME going forward. CONCLUSIONS:Residents graduating from CBME training programs offered a balanced perspective, including criticism and recognition of the potential value of CBME when implemented as intended. Their experiences provide a better understanding of residents' needs within CBME curricula, including greater balance and flexibility within programs of assessment and curricula. Many challenges that residents faced with CBME could be alleviated by greater accountability at program, institutional, and national levels. We conclude with actionable recommendations for addressing residents' needs in CBME.

Fostering interest in surgical careers is a persistent challenge for surgical educators in North America. The aim of this review was to identify modifiable factors that influence medical students’ decision to pursue a career in surgery. A systematic search was conducted in Embase, Education Source, Cochrane Central Register of Controlled Trials and MEDLINE, from database inception to July 2022. Studies reporting medical students’ self-reported motivating and deterring factors regarding a career in surgery were included. Methodologic quality was appraised using the Critical Appraisal Skills Programme checklists. This systematic review contains studies conducted in North America, and was conducted through Queen’s University School of Medicine in Kingston, Ontario, Canada. A total of 38 publications (n = 8479 students, 50.9

BACKGROUND:The aim of this study was to describe long-term (10-year) patient survival after arthroplasty for hip fracture and to determine what patient factors are associated with that outcome. METHODS:We performed a retrospective cohort analysis of patients ≥60 years old who underwent either hemiarthroplasty or total hip arthroplasty for femoral neck fracture between 2002 and 2009. We used routinely collected, validated health-care databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). We estimated the association between baseline variables and survival 10 years post-fracture using Poisson regression. Restricted cubic spline functions modeled the probability of 10-year survival by age and tested whether there was an inflection point after which the probability of 10-year survival decreased more rapidly. We estimated 10-year survival probabilities for different patient groups. RESULTS:There were 19,659 patients in the final cohort. Eighteen percent (3,564) of the patients were alive at 10 years postoperatively. Factors associated with a higher likelihood of 10-year survival included younger age, female sex (risk ratio [RR] = 1.56, 95% confidence interval [CI] = 1.46 to 1.68), lower American Society of Anesthesiologists (ASA) class (ASA I or II versus IV or V: RR = 1.96, 95% CI = 1.76 to 2.19), independent living status (RR = 2.68, 95% CI = 2.23 to 3.22), and fewer specific comorbidities. A threshold age of 73 years was the inflection point after which the probability of 10-year survival decreased more rapidly in females. Estimated 10-year survival probabilities ranged from 79.0% (95% CI = 75.5% to 82.5%) to 0.8% (95% CI = 0.6% to 1.0%). CONCLUSIONS:Approximately 1 in 6 patients live at least 10 years following a hip fracture. This study identifies baseline characteristics that predict survival greater than 10 years, including an age of <75 years, an ASA class of I or II, and independent living status prior to the hip fracture. Results can inform discussions around treatment choices, anticipated outcomes, and the natural history of hip fractures. LEVEL OF EVIDENCE:Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Objective: To assess the quality of narrative feedback given to surgical residents during the first 5 years of competency-based medical education implementation. Background: Competency-based medical education requires ongoing formative assessments and feedback on learners' performance. Methods: We conducted a retrospective cross-sectional study using assessments of entrustable professional activities (EPAs) in the Surgical Foundations curriculum at Queen's University from 2017 to 2022. Two raters independently evaluated the quality of narrative feedback using the Quality of Assessment of Learning score (0-5). Results: A total of 3900 EPA assessments were completed over 5 years. Of assessments, 57% (2229/3900) had narrative feedback documented with a mean Quality of Assessment of Learning score of 2.16 +/- 1.49. Of these, 1614 (72.4%) provided evidence about the resident's performance, 951 (42.7%) provided suggestions for improvement, and 499/2229 (22.4%) connected suggestions to the evidence. There was no meaningful change in narrative feedback quality over time (r = 0.067, P = 0.002). Variables associated with lower quality of narrative feedback include: attending role (2.04 +/- 1.48) compared with the medical student (3.13 +/- 1.12, P < 0.001) and clinical fellow (2.47 +/- 1.54, P < 0.001), concordant specialties between the assessor and learner (2.06 +/- 1.50 vs 2.21 +/- 1.49, P = 0.025), completion of the assessment 1 month or more after the encounter versus 1 week (1.85 +/- 1.48 vs 2.23 +/- 1.49, P < 0.001), and resident entrusted versus not entrusted to perform the assessed EPA (2.13 +/- 1.45 vs 2.35 +/- 1.66; P = 0.008). The quality of narrative feedback was similar for assessments completed under direct and indirect observation (2.18 +/- 1.47 vs 2.06 +/- 1.54; P = 0.153). Conclusions: Just over half of the EPA assessments of surgery residents contained narrative feedback with overall fair quality. There was no meaningful change in the quality of feedback over 5 years. These findings prompt future research and faculty development.

Background: Prescription opioid use places a considerable economic burden on health care systems. Older patients undergoing surgical procedures for painful conditions commonly receive opioids pre- and postoperatively, and are susceptible to adverse reactions. This study explores predictors of prolonged postoperative opioid use among older patients after lumbar spine surgery and the consequences in terms of health care utilization and costs.Methods: We conducted a retrospective population-based cohort study using Ontario administrative data from older adults undergoing spine surgery between 2006 and 2017. Data were analyzed from 90 days preoperatively to 1 year after hospital discharge, with last postoperative opioid prescriptions stratified into 90-day increments. We used multivariable ordinal logistic regression to identify predictors of long-term opioid use and generalized linear modelling to examine resource utilization and health care costs (2021 Canadian dollars).Results: Of 15 109 patients included, 40.8% received preoperative opioid prescriptions. Preoperative opioid use strongly predicted prolonged postoperative use (odds ratio [OR] 4.47, 95% confidence interval [CI] 4.16-4.79), with 48.3% of patients who received preoperative opioids continuing to use opioids for longer than 9 months, relative to 12.7% of those without preoperative use. Several other risk factors for prolonged use were identified. Patients receiving long-term postoperative opioids incurred greater health care costs relative to those with opioids prescribed for fewer than 90 days (OR 1.49, 95% CI 1.44-1.54).Conclusion: Among older adults undergoing spine surgery, preoperative opioid use was a strong predictor of prolonged postoperative use, which was associated with increased health care costs. These results form an important baseline for future studies evaluating strategies to reduce opioid use targeting older surgical populations. Contexte: L'utilisation d'opioï des vendus sur ordonnance impose un trè s lourd fardeau aux systè mes de santé. On les prescrit souvent en pé riode pré- et postopé ratoire aux malades â gé s qui subissent des interventions chirurgicales pour des maladies douloureuses et cela comporte des risques de ré actions indé sirables. Cette é tude explore les pré dicteurs d'une utilisation prolongé e des opioï des en pé riode postopé ratoire chez des personnes â gé es opé ré es à la colonne verté brale et son impact sur l'utilisation des ressources sanitaires et les coû ts associé s.Mé thodes: Nous avons procé dé à une é tude de cohorte populationnelle ré trospective à partir des donné es administratives de l'Ontario concernant les adultes â gé s ayant subi une chirurgie de la colonne entre 2006 et 2017. Les donné es ont é té analysé es pour la pé riode allant de 90 jours avant l'intervention à 1 an suivant le congé hospitalier, et les derniè res ordonnances postopé ratoires d'opioï des ont é té stratifié es par tranches de 90 jours. Nous avons utilisé l'analyse de ré gression logistique multivarié e ordinale pour identifier les pré dicteurs d'une utilisation prolongé e des opioï des et un modè le liné aire gé né ralisé pour examiner l'utilisation des ressources sanitaires et les coû ts associé s (dollars canadiens de 2021).Ré sultats: Parmi les 15 109 personnes incluses, 40,8 % avaient reç u une ordonnance d'opioï des avant leur intervention. L'utilisation d'opioï des en pé riode pré opé ratoire s'est ré vé lé ê tre un fort pré dicteur d'utilisation postopé ratoire prolongé e (rapport des cotes [RC] 4,47, intervalle de confiance [IC] de 95 % 4,16-4,79), et 48,3 % des malades ayant reç u des opioï des en pé riode pré opé ratoire ont continué de les utiliser pendant plus de 9 mois, contre 12,7 % des malades qui n'en avaient pas pris. Plusieurs autres facteurs de risque d'utilisation prolongé e ont é té identifié s. Les malades qui ont reç u des opioï des ont engendré des dé penses en soins de santé plus é levé es que les malades à qui on en avait prescrit pour moins de 90 jours (RC 1,49, IC de 95 % 1,44-1,54).Conclusion : Chez les adultes â gé s soumis à une chirurgie de la colonne, l'utilisation pré opé ratoire d'opioï des a é té un fort pré dicteur d'utilisation postopé ratoire prolongé e, qui a é té associé e à une hausse des coû ts de soins de santé. Ces ré sultats constituent une importante base de connaissances pour les futures é tudes qui é valueront des straté gies de ré duction du recours aux opioï des à l'intention de la patientè le chirurgicale â gé e.

Background: As Competency-Based Medical Education (CBME) is implemented across Canada, little is known about residents’ perceptions of this model. This study examined how Canadian residents understand CBME and their lived experiences with implementation. Methods: We administered a survey in 2018 with Likert-type and open-ended questions to 375 residents across Canada, of whom 270 were from traditional programs (“pre-CBME”) and 105 were in a CBME program. We used the Mann-Whitney test to examine differences across samples, and analyzed qualitative data thematically. Results: Three themes were identified across both groups: program outcome concerns, changes, and emotional responses. In relation to program concerns, both groups were concerned about the administrative burden, challenges with the assessment process, and feedback quality. Only pre-CBME residents were concerned about faculty engagement and buy-in. In terms of changes, both groups discussed a more formalized assessment process with mixed reactions. Residents in the pre-CBME sample reported greater concerns for faculty time constraints, assessment completion, and quality of learning experiences, whilst those in CBME programs reported being more proactive in their learning and greater self-reflection. Residents expressed strong emotional narrative responses including greater stress and frustration in a CBME environment. Conclusion: Findings demonstrate that residents have mixed feelings and experiences regarding CBME. Their positive experiences align with the aim of developing more self-directed learners. However, the concerns suggest the need to address specific shortcomings to increase buy-in, while the emotional responses associated with CBME may require a cultural shift within residency programs to guard against burnout.

BACKGROUND During the COVID-19 pandemic, opportunities for hands-on surgical and procedural skills training and practice were significantly reduced, as many curricular activities were deferred or converted to a virtual format. This study focused on whether these changes contributed to increased anxiety and decreased confidence for medical students performing these skills. METHODS The Surgical Skills Technology Elective Program (SSTEP) is an annual five-day intensive procedural skills program after second-year medical school. Surveys assessing anxiety and confidence with respect to procedural skills were distributed and completed before and after SSTEP in 2016 and 2022. RESULTS Pre-SSTEP scores were higher for anxiety and lower for confidence in the 2022 cohort compared to the prepandemic group. Post-SSTEP scores for anxiety and confidence were comparable between cohorts. CONCLUSIONS Curricular changes and restrictions during the pandemic likely played a major role in the 2022 cohort having more anxiety and less confidence in their skills than prepandemic cohorts. However, these changes were effectively mitigated after participation in SSTEP. Medical schools should consider using and expanding on in-person bootcamps to support those with decreased exposure to surgical and procedural skills related to resource constraints and/or curricular changes.

Aims This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. Methods We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. Results Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. Conclusion The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients. Cite this article: Bone Joint J 2023;105-B(2):180–189.

Background: Although uncommon, pneumothorax is a potentially serious complication following open reduction and internal fixation (ORIF) of clavicle fractures. In many centres it is routine practice to obtain postoperative chest radiographs following ORIF of clavicle fractures to assess for iatrogenic pneumothorax. Given the need to contain health care costs, the low sensitivity for detecting small pneumothorax and a desire to decrease patient radiation exposure, the practice of ordering chest radiographs following ORIF of clavicle fractures may be unnecessary. Methods: All patients undergoing ORIF of clavicle fractures with plate and screw fixation at Kingston Health Sciences Centre between April 2009 and June 2020 were identified from the Discharge Abstract Database (inpatient) and National Ambulatory Care Reporting System (outpatient) using relevant Canadian Classification of Health Intervention procedure codes. Charts were manually reviewed to confirm diagnosis and procedure, and patients with preoperative pneumothorax were excluded. The frequency of postoperative chest radiograph and pneumothorax detection were calculated. Results: Among the 292 patients who underwent ORIF of clavicle fractures during the study period, 17 were excluded for having a pneumothorax on preoperative chest radiograph. Of the remaining 275 patients, 101 (36.7%) had postoperative chest radiographs, of whom none were found to have postoperative iatrogenic pneumothorax. Conclusion: Since 2009, the rate of routine postoperative chest radiography following ORIF of clavicle fractures is 36.7% at our centre. During this time period, none of the 101 patients who had postoperative chest radiographs had a postoperative iatrogenic pneumothorax. To our knowledge, this is the largest series of patients available, and our findings confirm those of several smaller studies. Owing to the low rate of postoperative iatrogenic pneumothorax, we conclude that postoperative chest radiography is unnecessary following ORIF of clavicle fractures.

AIMS This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. METHODS We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. RESULTS Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. CONCLUSION The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients.Cite this article: Bone Joint J 2023;105-B(2):180-189.