Outcomes following hip fracture surgery in adults with schizophrenia in Ontario, Canada: A 10-year population-based retrospective cohort study.

OBJECTIVE: To understand immediate and long-term outcomes following hip fracture surgery in adults with schizophrenia. METHODS: Retrospective population-based cohort study leveraging health administrative databases from Ontario, Canada. Individuals aged 40-105 years with hip fracture surgery between April 1, 2009 and March 31, 2019 were included. Schizophrenia was ascertained using a validated algorithm. Outcomes were: 30-day mortality; 30-day readmission; 1-year survival; and subsequent hip fracture within 2 years. Analyses incorporated Generalized Estimating Equation models, Kaplan-Meier curves, and Fine-Gray competing risk models. RESULTS: In this cohort study of 98,126 surgically managed hip fracture patients, the median [IQR] age was 83[75-89] years, 69.2% were women, and 3700(3.8%) had schizophrenia. In Fine-Gray models, schizophrenia was associated with subsequent hip fracture (sdRH, 1.29; 95% CI, 1.09-1.53), with male patients with schizophrenia sustaining a refracture 50 days earlier. In age- and sex-adjusted GEE models, schizophrenia was associated with 30-day mortality (OR, 1.31; 95% CI, 1.12-1.54) and readmissions (OR, 1.40; 95% CI, 1.25-1.56). Kaplan-Meier survival curves suggested that patients with schizophrenia were less likely to be alive at 1-year. CONCLUSIONS: Study highlights the susceptibility of hip fracture patients with schizophrenia to worse outcomes, including refracture, with implications for understanding modifiable processes of care to optimize their recovery.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort.

BACKGROUND: Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture. METHODS: A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery. RESULTS: In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race. INTERPRETATION: Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly.

BACKGROUND: Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients. METHODS: As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects. RESULTS: In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication. CONCLUSIONS: Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Cost-Utility Analysis of the Ontario Fracture Screening and Prevention Program.

BACKGROUND: The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications). METHODS: We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported. RESULTS: The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP. CONCLUSIONS: The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Identifying and Addressing Barriers to Osteoporosis Treatment Associated with Improved Outcomes: An Observational Cohort Study.

OBJECTIVE: To identify and address patient-reported barriers in osteoporosis care after a fracture. METHODS: A longitudinal cohort of fragility fracture patients over 50 years of age was seen in a provincewide fracture liaison service. Followup interviews were done at 6 months for osteoporosis care indicators. Univariate statistics were used to describe baseline characteristics, osteoporosis-related outcomes, and reasons cited for not achieving them. Two phases of this program were compared (Phase I: education and communication, and Phase II: risk assessment education and communication). Phase II was further divided into those who fully participated and those who declined. RESULTS: Phase I (n = 3997) had lower testing and treatment rates than Phase II (n = 1363). Rates were highest in those confirmed as having participated in Phase II (n = 569). Phase II nonparticipants (n = 794) had results as in Phase I. In Phase I, the main patient-reported barriers for not visiting their physician or not having a bone mineral density (BMD) test were patient- and physician-oriented (e.g., being instructed by their physician to not have the BMD test). In Phase II, BMD testing was part of the program, thus the main barriers were around treatment choices. Phase II eligible nonparticipants experienced many of the same barriers as Phase I patients, with lower BMD testing rates (54.9% and 65.4%, respectively). CONCLUSION: Evaluating and addressing barriers to guideline implementation reduced those barriers and was associated with higher downstream treatment rates. Monitoring barriers in a program like this provides useful insights for program changes and research interventions.

Vitamin D Use and Health Outcomes After Surgery for Hip Fracture.

Daily administration of vitamin D is important for maintaining bone homeostasis. The orthopedic community has shown increased interest in vitamin D supplementation and patient outcomes after fracture. The current study used data from a large hip fracture trial to determine the proportion of patients who consistently used vitamin D after hip fracture surgery and to determine whether supplementation was associated with improved health-related quality of life and reduced reoperation rates. The FAITH study is a multicenter trial of elderly patients with femoral neck fracture treated with internal fixation. The current study asked a subset of patients included in the FAITH study about vitamin D supplementation and categorized them as consistent users, inconsistent users, or nonusers. This study also evaluated whether supplementation was associated with improved quality of life and reduced reoperation rates. The final analysis included 573 patients (mean age, 74.1 years; female, 66.3%; nondis-placed fractures, 72.4%). A total of 18.7% of participants reported no use of vitamin D, 35.6% reported inconsistent use, and 45.7% reported consistent use. Adjusted analysis found that consistent supplementation was associated with a 2.42 increase of the Short Form-12 physical component score 12 months postoperatively (P=.033). However, supplementation was not associated with reduced reoperation rates (P=.386). Despite guidelines recommending vitamin D supplementation, a low proportion of elderly patients with hip fracture use vitamin D consistently, suggesting a need for additional strategies to promote compliance. This study found that the use of vitamin D was associated with a statistically significant but not clinically significant improvement in health-related quality of life after hip fracture. Further research is needed to confirm these findings. [Orthopedics. 2017; 40(5):e868-e875.].

Fracture Prevention in the Orthopaedic Environment: Outcomes of a Coordinator-Based Fracture Liaison Service.

BACKGROUND: Fracture liaison services focus on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. This study describes key clinical outcomes including bone mineral densitometry, physician assessment, and pharmacotherapy initiation in pharmacotherapy-naïve patients undergoing treatment for fragility fracture in a Canadian fracture liaison service. METHODS: We determined rates of post-fracture investigation and treatment for inpatients and outpatients with a fragility fracture seen in a coordinator-based fracture liaison service at an urban university trauma hospital. The program identified distal radial, proximal femoral, proximal humeral, and vertebral fragility fractures in female patients ≥40 years of age and male patients ≥50 years of age and provided education, bone mineral densitometry, inpatient consultation or outpatient specialist or primary care physician referral for bone health management, and documented patient follow-up. RESULTS: The 2,191 patients with a fragility fracture were not taking anti-osteoporosis pharmacotherapy at the time of identification (862 inpatients and 1,329 outpatients). Eighty-four percent of inpatients and 85% of outpatients completed a bone mineral densitometry as recommended. Fifty-two percent of patients with proximal femoral fracture, 29% of patients with vertebral fracture, 26% of patients with proximal humeral fracture, and 20% of patients with distal radial fracture had osteoporosis confirmed on the basis of a bone mineral densitometry T-score of ≤-2.5 at the femoral neck or L1 to L4. Eighty-five percent of inpatients and 79% of outpatients referred for bone health management were assessed by a specialist or primary care physician. Of the patients who attended their appointments, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication. CONCLUSIONS: A high rate of education, evaluation, and pharmacological treatment, if indicated, can be achieved through a coordinator-facilitated fracture liaison service program. CLINICAL RELEVANCE: Fracture prevention programs are currently engaged in establishing and modifying fracture liaison services in a quest for practical and effective models. The program described in this article exemplifies a coordinator-based model that produced good outcomes.

A Missed Opportunity in Bone Health: Vitamin D and Calcium Use in Elderly Femoral Neck Fracture Patients Following Arthroplasty.

INTRODUCTION: Introduction: Adequate calcium and vitamin D from diet and supplementation is recommended for elderly hip fracture patients. Using data from the multinational hip fracture arthroplasty trial (HEALTH), we determined the proportion of patients who consistently took vitamin D and calcium and which characteristics/prescribing practices were associated with consistency of supplement use. METHODS: HEALTH is a multicenter randomized trial of elderly hip fracture patients treated with hemi-arthroplasty and total hip arthroplasty. Patients were categorized as consistent users, inconsistent users, or nonusers of calcium and vitamin D. We used multinomial regression to determine the characteristics associated with calcium and vitamin D use. RESULTS: 603 HEALTH participants were included in the analysis. 34.7% of patients never took vitamin D within 12 months after surgery, 26.2% took vitamin D inconsistently, and 39.1% took vitamin D consistently. 36.0% of patients never took calcium within 12 months after surgery, 28.4% took calcium inconsistently, and 35.7% took calcium consistently. There was great variation in prescribed/recommended doses. Compared to nonusers, consistent users of the supplements were more likely to be female, North American, prescribed/recommended vitamin D and/or calcium postoperatively, and presented to a facility with comprehensive fragility fracture protocols. CONCLUSIONS: A low proportion of elderly hip fracture patients are consistently taking vitamin D and calcium, which may contribute to poorer bone health. Surgeons should be educated to prescribe/ recommend vitamin D and calcium, institutions should develop comprehensive fragility fracture protocols and patient education strategies to ensure that patients with osteoporosis receive bone health management beyond fracture care.

Improvements in osteoporosis testing and care are found following the wide scale implementation of the Ontario Fracture Clinic Screening Program: An interrupted time series analysis.

We evaluated a system-wide impact of a health intervention to improve treatment of osteoporosis after a fragility fracture. The intervention consisted of assigning a screening coordinator to selected fracture clinics to identify, educate, and follow up with fragility fracture patients and inform their physicians of the need to evaluate bone health. Thirty-seven hospitals in the province of Ontario (Canada) were assigned a screening coordinator. Twenty-three similar hospitals were control sites. All hospitals had orthopedic services and handled moderate-to-higher volumes of fracture patients. Administrative health data were used to evaluate the impact of the intervention.Fragility fracture patients (≥50 years; hip, humerus, forearm, spine, or pelvis fracture) were identified from administrative health records. Cases were fractures treated at 1 of the 37 hospitals assigned a coordinator. Controls were the same types of fractures at the control sites. Data were assembled for 20 quarters before and 10 quarters after the implementation (from January 2002 to March 2010). To test for a shift in trends, we employed an interrupted time series analysis-a study design used to evaluate the longitudinal effects of interventions, through regression modelling. The primary outcome measure was bone mineral density (BMD) testing. Osteoporosis medication initiation and persistence rates were secondary outcomes in a subset of patients ≥66 years of age.A total of 147,071 patients were used in the analysis. BMD testing rates increased from 17.0% pre-intervention to 20.9% post-intervention at intervention sites (P < .01) compared with no change at control sites (14.9% and 14.9%, P = .33). Medication initiation improved significantly at intervention sites (21.6-23.97%; P = .02) but not at control sites (17.5-18.5%; P = .27). Persistence with bisphosphonates decreased at all sites, from 59.9% to 56.4% at intervention sites (P = .02) and more so from 62.3% to 54.2% at control sites (P < .01) using 50% proportion of days covered (PDC 50).Significant improvements in BMD testing and treatment initiation were observed after the initiation of a coordinator-based screening program to improve osteoporosis management following fragility fracture.

Increased risk of complications following total joint arthroplasty in patients with rheumatoid arthritis.

OBJECTIVE: Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are based on patients with osteoarthritis (OA); less is known about outcomes in rheumatoid arthritis (RA). Using a validated algorithm for identifying patients with RA, we undertook this study to compare the rates of complications among THA and TKA recipients between those with RA and those without RA. METHODS: In patients who underwent a first primary elective THA or TKA between 2002 and 2009, those with RA were identified using a validated algorithm: a hospitalization with a diagnosis code for RA or 3 physician billing claims with a diagnosis code for RA, with at least 1 claim by a specialist (rheumatologist, orthopedic surgeon, or internist) in a 2-year period. Recipients with diagnostic codes suggesting an inflammatory arthritis, but not meeting RA criteria, were classified as having inflammatory arthritis. All remaining patients were deemed to have OA. Cox proportional hazards models, censored on death, were used to determine the relationship between the type of arthritis and the occurrence of specific complications, adjusting for potential confounders (age, sex, comorbidity, and provider volume). RESULTS: We identified 43,997 eligible THA recipients (3% with RA) and 71,793 eligible TKA recipients (4% with RA). Total joint arthroplasty recipients with RA had higher age and sex-standardized rates of dislocation following THA (2.45%, compared with 1.21% for recipients with OA) and higher age and sex-standardized rates of infection following TKA (1.26%, compared with 0.84% for recipients with OA). Controlling for potential confounders, recipients with RA remained at increased risk of dislocation within 2 years of THA (adjusted hazard ratio [HR] 1.91, P = 0.001) and remained at increased risk of infection within 2 years of TKA (adjusted HR 1.47, P = 0.03) relative to recipients with OA. CONCLUSION: Patients with RA are at higher risk of dislocation following THA and are at higher risk of infection following TKA relative to those with OA. Further research is warranted to elucidate explanations for these findings, including the roles of medication profile, implant choice, postoperative antibiotic protocol, and method of rehabilitation following joint replacement.

Key outcomes are usually not reported in published fracture secondary prevention programs: results of a systematic review.

OBJECTIVE: A secondary analysis of a systematic review on interventions to improve osteoporosis (OP) investigation and treatment was conducted to examine reported key outcomes: (1) the cost of the intervention; (2) the proportion of patients taking OP medication beyond 6 months of the intervention; and (3) the proportion of patients who re-fractured. METHODS: Fifty-seven articles reporting on 54 studies (64 interventions) from 11 countries were included. Intervention studies to improve OP management were eligible if they were conducted in an orthopedic setting and included primary data on ≥20 patients presenting with a hip fracture or any fragility fracture. To compare outcome data across all interventions regardless of study design, an equated proportion (EP) using a denominator based on the intention-to-treat principle was derived. Whether a cost analysis had been conducted, the EP of patients who were taking medication beyond 6 months of the intervention, and the EP of patients who re-fractured during the study period were documented. RESULTS: Of the 54 studies, 2 reported a cost analysis and demonstrated that the interventions were at least cost-effective. The EP for medication use beyond 6 months of the intervention ranged from 17 to 56% for four studies. The EP for re-fracture ranged from 0 to 5% for four studies. CONCLUSION: Most interventions did not report key outcomes. In addition, authors used varying time frames for re-fracture and medication use, making direct comparisons impossible. Authors should consider including intervention costs, medication use beyond 6 months of the intervention, and re-fracture data in future fracture secondary prevention programs.

Strategies used by an osteoporosis patient group to navigate for bone health care after a fracture.

OBJECTIVE: To examine experiences and behaviours with bone health management post-fracture among members of a national osteoporosis (OP) patient group. METHODS: A qualitative study was conducted in English-speaking members of the group who had sustained a fragility fracture at 50+ years old and were not taking OP pharmacotherapy at the time of that fracture. Participants were recruited through an advertisement in the patient group newsletter and interviewed for ~1 h by telephone, responding to questions regarding visits to health care providers and their behaviours regarding bone health. We analysed the data following Giorgi's methodology. RESULTS: Twenty-eight eligible participants (26 females, two males; 78% response rate) aged 51-89 years old completed an interview. More than half of our participants described effective consumer behaviours, including making requests of health care providers for referrals to bone specialists, bone mineral density tests, and prescription medication. CONCLUSION: Members of an OP patient group described effective consumer behaviours that could be incorporated as skill sets in post-fracture interventions to improve bone health.

A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis.

OBJECTIVE: Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA. METHODS: Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively. RESULTS: Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity). CONCLUSION: The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA.

Secondary causes of osteoporosis in fracture patients.

OBJECTIVE: Identification and treatment of osteoporosis in the fragility fracture population and interventions to reduce the risk of future fracture are improving in orthopaedic practice. This study investigated the prevalence of vitamin D insufficiency and deficiency and other secondary causes of low bone density in patients who have sustained a fragility fracture and were referred from fracture clinic to a metabolic bone disease clinic (MBDC) for further assessment. DESIGN: Retrospective chart audit. SETTING: University hospital fracture clinic. PATIENTS: Three hundred ninety-nine patients referred from the orthopaedic division to the MBDC over a 3-year period. INTERVENTION: A standardized chart audit form was developed, and electronic charts were retrospectively audited. MAIN OUTCOME MEASUREMENTS: Secondary causes of osteoporosis and routine blood test results. RESULTS: Three hundred eight of 399 patients had blood investigations completed. A total of 98 patients (32%) had 125 secondary causes of osteoporosis other than vitamin D deficiency or insufficiency recorded in their electronic chart, including medication use, premature ovarian failure, hypogonadism, smoking, excessive alcohol use, renal impairment, gastrointestinal conditions, and endocrine conditions. Mean serum vitamin D level was 69.0 nmol/L in 83 men and 75.4 nmol/L in 186 women. Serum vitamin D levels were deficient at ≤25 nmol/L in 7 patients, insufficient at 26-74 nmol/L in 137 patients, and sufficient at ≥75 nmol/L in 125 patients. Investigation of causes of secondary osteoporosis can inform and influence specific treatment regimens. CONCLUSIONS: More than one-half of patients sustaining a fragility fracture and referred to the MBDC were vitamin D insufficient or deficient, and nearly one-third had a secondary cause of osteoporosis other than vitamin D insufficiency/deficiency. A standardized list of blood and urine analyses and radiographs has been implemented for fragility fracture patients and selected other fracture patients who are undergoing investigation for osteoporosis. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Hand appearance as a patient motivation for surgery and a determinant of satisfaction with metacarpophalangeal joint arthroplasty for rheumatoid arthritis.

PURPOSE: To determine patient motivations for surgery and satisfaction with outcomes for metacarpophalangeal (MCP) joint arthroplasty in 3 domains (appearance, function, and pain) and whether patient-reported satisfaction correlates with standard outcome measures. METHODS: In a randomized controlled trial of MCP joint implants, 33 patients with rheumatoid arthritis had primary MCP joint arthroplasty: 15 hands received Swanson implants, and 18 received NeuFlex implants. Range of motion, ulnar drift, grip strength, Sollerman hand function test, and the Michigan Hand Questionnaire were collected before surgery and 1 year after surgery. Preoperative patient motivations for and expectations of MCP joint arthroplasty were assessed for function, pain, and appearance. Patient-perceived improvement and satisfaction within the 3 domains and global satisfaction were assessed after surgery. RESULTS: Function was rated the most important motivator for surgery by 31 patients, pain by 22, and appearance by 15. Twenty-six patients rated 2 or more motivators equally high. Michigan Hand Questionnaire subscores were moderately correlated or weakly correlated with patient-reported satisfaction. The Sollerman score was weakly correlated with patient-reported satisfaction. Range of motion, ulnar drift, and grip strength were not correlated with patient-reported satisfaction. More patients stated that a much better improvement was obtained for appearance than for function or pain relief. CONCLUSIONS: Patient expectations of MCP joint arthroplasty were uniformly high. The greatest motivation for surgery was functional improvement. Pain was highly ranked, and 25 patients rated hand appearance as the first or second motivator. Patient satisfaction correlated poorly with traditional outcome measures and moderately with patient-reported outcomes. We conclude that appearance should be considered an important motivator for surgery and determinant of satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

A postfracture initiative to improve osteoporosis management in a community hospital in ontario.

BACKGROUND: Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease. METHODS: We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible. RESULTS: Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely to have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline. CONCLUSIONS: A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation.

NeuFlex and Swanson metacarpophalangeal implants for rheumatoid arthritis: prospective randomized, controlled clinical trial.

PURPOSE: To compare postoperative range of motion (ROM) and function in a randomized prospective trial of Swanson and NeuFlex metacarpophalangeal (MCP) joint implants. METHODS: A total of 33 patients who had rheumatoid arthritis underwent primary MCP arthroplasty of all 4 fingers in 40 hands; 20 received Swanson implants and 20 received NeuFlex implants. Exclusion criteria included diagnosis of other connective tissue disorders and previous MCP joint surgery. All participants followed the same postoperative rehabilitation protocol. The primary outcome measure was active MCP flexion. Secondary outcomes included active MCP extension, arc of motion, ulnar drift, function (Jamar grip strength and Sollerman hand function test), and the Michigan Hand Questionnaire. Patients were assessed preoperatively and 12 months postoperatively. RESULTS: Patients' mean age was 62.5 years (Swanson) and 58.1 years (NeuFlex) (p = .03). A total of 19 of 20 hands (Swanson) and 14 of 20 hands (NeuFlex) were from female patients. Preoperative active ROM was not significantly different. At follow-up, both groups demonstrated increased active extension and arc of motion (p < .001), reduced active flexion and improved ulnar deviation (p < .001), increased mean Sollerman and Michigan Hand Questionnaire domain scores (p < .001), and improved grip strength (p = .03). Active MCP flexion was significantly greater in all 4 digits of hands with NeuFlex implants compared with Swanson implants. The NeuFlex group demonstrated a greater total arc of motion in the little finger. Implant groups were not significantly different by individual digit for active MCP extension, ulnar drift, and composite flexion. Functional outcomes did not differ between groups. Patients with Swanson implants reported higher Michigan Hand Questionnaire scores in the function and aesthetics domains. CONCLUSIONS: Both implant groups obtained satisfactory clinical improvement after MCP reconstruction of the hand. The NeuFlex group demonstrated superior ROM, whereas the Swanson group had better self-reported function and aesthetics, but not objectively measured function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

'If it was osteoporosis, I would have really hurt myself.' Ambiguity about osteoporosis and osteoporosis care despite a screening programme to educate fragility fracture patients.

RATIONALE, AIMS AND OBJECTIVES: Behaviour change models suggest that people need clear information about their susceptibility to disease and knowledge of treatment recommendations in order to change their behaviour. The purpose of this qualitative study was to examine fracture patients' understanding of osteoporosis (OP) and OP care after being screened for, and educated about, OP in a fracture clinic. METHODS: We conducted five focus groups with 24 patients (18 women, six men) aged 47-80 years old who were screened for OP through an urban fracture clinic. Participants were asked about their awareness of OP and their status of bone mineral density (BMD) testing and OP treatment. RESULTS: Twenty participants vocalized at least one expression of ambiguity regarding OP and/or treatment recommendations conveyed by the screening programme staff. Participants were ambiguous about the cause of their fracture, the BMD test process and results, and the presentation of OP. They were also ambiguous about the amount and type of medication and supplements recommended. CONCLUSIONS: Despite a standardized screening programme in which OP was addressed in fragility fracture patients, ambiguity about diagnosis, testing and treatment were described. Efforts to clarify information relayed to fracture patients about their condition and recommended care need to extend beyond the fracture clinic so that health care providers can promote long-term adherence to these recommendations.

Increased tender point counts before and after total hip arthroplasty are associated with poorer outcomes but are not individually predictive.

In a prospective study, total hip arthroplasty (THA) patients were assessed preoperatively and postoperatively (n = 95) to determine if tender points (TPs) are associated with poor THA outcomes. Patients with high follow-up TP counts had higher visual analog scale (VAS) for pain and sleep, higher follow-up Western Ontario and McMaster Universities Arthritis Index (pain, stiffness, function), lower Health Assessment Questionnaire, Harris Hip, and Short Form 36 (physical functioning, bodily pain, physical component summary) scores. High follow-up TP were associated with increased pain, pain not relieved by surgery, poor function, and poor sleep. Visual analog scale pain and sleep, Short Form 36 (physical functioning, bodily pain), Western Ontario and McMaster Universities Arthritis Index, Health Assessment Questionnaire, and Harris hip scores improved significantly after THA; TP scores did not. Higher preoperative TP were predictive of higher follow-up TP but were poorly predictive of poor outcome measures after surgery in individual patients, suggesting that preoperative TPs are not [corrected] contraindicative for THA.