Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age.

BACKGROUND: Geriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level. METHODS: Using administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality. RESULTS: A total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years ("younger") and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years ("older"). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001). CONCLUSION: Older patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.

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] 1.25­3.67, p = 0.0054) and amputation (quintile 4 v. quintile 1: OR 3.56, 95% CI 1.01­12.4, 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 0.76­0.888, 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.

Contexte: Malgré l'incidence accrue des fractures et les inégalités dans la prestation des soins chez les patients au statut socio-économique précaire, peu d'études se sont penchées sur les résultats de la chirurgie pour fracture chez cette population. Nous avons voulu vérifier si une situation socio-économique précaire influait sur les complications et la prise en charge subséquente des patients marginalisés/itinérants après une chirurgie pour fracture de la cheville. Méthodes: Au cours de cette étude de cohorte rétrospective basée dans la population regroupant 202 hôpitaux en Ontario, au Canada, nous avons évalué 45 444 patients ayant subi une réduction ouverte avec fixation interne (ROFI) pour fracture de la cheville, effectuée par 710 chirurgiens différents entre le 1er janvier 1994 et le 31 décembre 2011. Des modèles de régression logistique multivariée ont servi à évaluer le lien entre le statut précaire et les résultats à court terme (au cours de l'année) (retrait de l'implant, réintervention pour ROFI, irrigation et débridement en raison d'une infection, et amputation). Des modèles d'analyse multivariée à risques proportionnels de Cox ont servi à évaluer les résultats à plus long terme, jusqu'à 20 ans (fusion de la cheville et arthroplastie de la cheville). Résultats: Le risque d'irrigation et débridement (quintile 5 c. quintile 1 : rapport des cotes [RC] 2,14, intervalle de confiance [IC] de 95 % 1,25­3,67, p = 0,0054) et d'amputation (quintile 4 c. quintile 1 : RC 3,56, IC de 95 % 1,01­12,4, p = 0,0466) était proportionnel à la précarité de la situation des individus. Les patients moins défavorisés étaient moins susceptibles de se faire retirer leurs implants (quintile 5 c. quintile 1 : RC 0,822, IC de 95 % 0,76­0,888, p < 0,0001). On n'a observé aucune corrélation entre la marginalisation et une réintervention pour ROFI, fusion de la cheville ou arthroplastie de la cheville. Conclusion: Les patients marginalisés sont exposés à un risque significativement plus élevé d'infection et d'amputation après un traitement chirurgical pour fracture de la cheville. Cependant, de telles complications demeurent extrêmement rares chez cette population. Un statut socioéconomique précaire ne devrait pas empêcher les patients marginalisés de recevoir une chirurgie lors de fractures instables de la cheville.

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.

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.

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.

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.

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.

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.

Which patients are most likely to benefit from total joint arthroplasty?

OBJECTIVE: To evaluate patient predictors of good outcome following total joint arthroplasty (TJA). METHODS: A population cohort with hip/knee arthritis (osteoarthritis [OA] or inflammatory arthritis) ages ≥55 years was recruited between 1996 and 1998 (baseline) and assessed annually for demographics, troublesome joints, health status, and overall hip/knee arthritis severity using the Western Ontario and McMaster Universities OA Index (WOMAC). Survey data were linked with administrative databases to identify primary TJAs. Good outcome was defined as an improvement in WOMAC summary score greater than or equal to the minimal important difference (MID; 0.5 SD of the mean change). Logistic regression and Akaike's information criterion were used to determine the optimal number of predictors and the best model of that size. Log Poisson regression was used to determine the relative risk (RR) for a good outcome. RESULTS: Primary TJA was performed in 202 patients (mean age 71.0 years; 79.7% female; 82.7% with >1 troublesome hip/knee; 65.8% knee replacements). Mean improvement in WOMAC summary score was 10.2 points (SD 18.05; MID 9 points). Of these patients, 53.5% experienced a good outcome. Four predictors were optimal. The best 4-variable model included pre-TJA WOMAC, comorbidity, number of troublesome hips/knees, and arthritis type (C statistic 0.80). The probability of a good outcome was greater with worse (higher) pre-TJA WOMAC summary scores (adjusted RR 1.32 per 10-point increase; P < 0.0001), fewer troublesome hips/knees (adjusted RR 0.82 per joint; P = 0.002), OA (adjusted RR for rheumatoid arthritis versus OA 0.33; P = 0.009), and fewer comorbidities (adjusted RR per condition 0.88; P = 0.01). CONCLUSION: In an OA cohort with a high prevalence of multiple troublesome joints and comorbidity, only half achieved a good TJA outcome, defined as improved pain and disability. A more comprehensive assessment of the benefits and risks of TJA is warranted.

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.

A Dedicated Orthopaedic Trauma Room Improves Efficiency While Remaining Financially Net Positive.

OBJECTIVES: To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances. DESIGN: Retrospective cost-analysis. SETTING: Single midsized academic-affiliated community hospital in Toronto, Canada. PARTICIPANTS: All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included. INTERVENTION: Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed. MAIN OUTCOME MEASUREMENTS: The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries. RESULTS: One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476. CONCLUSIONS: Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal femoral replacement or internal fixation for management of periprosthetic distal femur fractures: A systematic review.

BACKGROUND: The number of periprosthetic fractures above a total knee arthroplasty continues to increase. These fractures are associated with a high risk of morbidity and mortality. Techniques for addressing these fractures include open reduction internal fixation (ORIF) and revision arthroplasty, including distal femoral replacement (DFR). The primary aim of this review is to compare mortality and reoperation rates between ORIF and DFR when used to treat periprosthetic distal femur fractures. METHODS: A systematic review including MEDLINE, Embase and Cochrane Library databases was completed from inception to April 10, 2021. Studies including a comparator cohort were meta-analyzed. RESULTS: Fourteen studies were identified for inclusion, of which, five had sufficient homogeneity for inclusion in a meta-analysis. 30-day and 2-year mortality was 4.1% and 14.6% in the DFR group. There was no statistically significant difference between ORIF and DFR (log Odds-Ratio (OR) = -0.14, 95 %CI: -0.77 to 0.50). The reoperation rate in the DFR group was 9.3% versus 14.8% for ORIF, with no difference between groups (log OR = 0.10, 95 %CI: -0.59 to 0.79). There was no difference in rates of deep infection (log OR = 0.22, 95 %CI: -0.83 to 1.28). Direct comparison of functional outcomes was not possible, though did not appear significant. CONCLUSION: DFR in the setting of periprosthetic distal femur fractures is equivalent to ORIF with respect to mortality and reoperation rate and thus a safe and reliable treatment strategy. DFR may be more reliable in complex fracture patterns where the ability to obtain adequate fixation is difficult.

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.

Referral practices for spinal surgery are poorly predicted by clinical guidelines and opinions of primary care physicians.

BACKGROUND: Degenerative disease of the lumbar spine is common. Although surgery can benefit selected patients, variation in surgical referrals reduces overall access to care. OBJECTIVES: To compare the actual referral practices for patients with degenerative disease of the lumbar spine with recommendations for surgical referral based on clinical practice guidelines (CPGs) and family physician (FP) opinions. RESEARCH DESIGN: An expert panel of primary and specialist physicians, using a Delphi process, came to a consensus on referral recommendations from CPGs based on a series of clinical vignettes. The vignettes were also presented to practicing FPs in Ontario, Canada, to determine their preferences for (or likelihood of) referral. SUBJECTS: We assembled a 10-member multispecialty expert panel. Practicing FPs were randomly sampled, stratified by county, and their patients were sampled purposefully by the FP. MEASURES: Respondents, both panelists and FPs, were asked to rate the appropriateness of surgical referral for a series of clinical vignettes. Patients reported their clinical symptoms and whether they had been referred to a surgeon. Using random-effects probit regression, predictions were compared with actual referral. Receiver operating characteristic curves were constructed and area under the curve (AUC) was measured. RESULTS: Consensus of the panel on recommendations for referral was achieved after 2 iterations (Cronbach alpha = 0.96). Based on responses from 107 patients and 61 FPs, we found poor concordance of both predicted FP preferences (AUC 0.57) and CPG recommendations (AUC 0.64) with actual referral. CONCLUSIONS: Referral practices are poorly predicted by CPG recommendations and individual FP opinions, based on clinical factors. Understanding other nonclinical factors may be more important in reducing variation in referrals and improving access.

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.

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.

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.

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.

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.