A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes.

Background: Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting. Methods: The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice. Results: The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care. Conclusions: Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.

Clinical impact of positive Propionibacterium acnes cultures in orthopedic surgery.

BACKGROUND: The clinical significance of a positive culture to Propionibacterium acnes in orthopedic specimens remains unclear, whether about its role as a contaminant or a pathogen, or its impact as a coinfectant. Therefore, we performed a retrospective study to provide a more accurate description of the clinical impact of P. acnes in an orthopedic population aiming to determine: 1) if there is a clinical difference between P. acnes infection and contamination? 2) If there is a clinical difference between P. acnes monoinfection, and coinfection. HYPOTHESIS: There is a clinical difference between P. acnes infection and contamination. MATERIALS AND METHODS: Patients were selected over a five-year period, and those with a minimum of one positive culture for P. acnes, from any intraoperative orthopedic tissue sample, were included in the study. P. acnes infection was defined as the isolation of P. acnes from≥2 specimens, or in only one specimen, in the presence of typical perioperative findings and/or local signs of infection. RESULTS: A total of 68 patients had a positive P. acnes culture, 35 of which were considered to be infected. The infections affected mostly males (29/35-83%), occurred mostly in shoulders (22/35-63%), and at a site already containing an orthopedic implant (32/35-91%). Local inflammatory signs were present in half of the cases when an infection was diagnosed. Coinfection with other pathogens was present in 31% of patients (11/35). When comparing patients coinfected with P. acnes, and those who were monoinfected, the latter presented less often with local inflammatory signs. Recurrence rate was 24% (8/35) and the only risk factor for recurrence was the presence of a monoinfection. DISCUSSION: This study confirms the pathogenicity of P. acnes in an orthopedic population, as it is present in multiple samples in the same patient, and because it is present in cultures from cases with clinical recurrence. Our study showed that monoinfections differ from coinfections mainly by their higher risk of recurrence. LEVEL OF EVIDENCE: Level IV retrospective case series.

Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.

BACKGROUND: Older patients tend to have acetabular fractures with medial displacement patterns and associated comminution, particularly of the quadrilateral surface. Our goal was to investigate the appropriateness of open reduction and internal fixation using an infra-pectineal buttress plate for osteopenic acetabular fractures. MATERIALS AND METHOD: We conducted a retrospective review involving twenty one consecutive patients over the course of 4 years with an acetabular fracture in an academic level 1 trauma centre. We performed the modified Stoppa approach with buttress plating of the quadrilateral surface. Clinical examination radiographs was done using criteria described by Matta. Functional outcome was evaluated using surveys including SF-12, WOMAC, Harris Hip score and modified Postel Merle D'Aubigne. RESULTS: Average follow-up was 4.2 years with a minimum of 2 years. Mean age for patients was 64.3 years. We obtained anatomic reduction in 52.4% (11/21) of cases, imperfect reduction in 38.1% (8/21) of cases and poor reduction in 9.5% (2/21) of cases. Significant loss of reduction was seen in 2 patients. A superior dome impaction (a Gull sign) was correlated to arthroplasty (p=0.02) and reduced quality of initial reduction (p=0.02). Two patients required re-intervention with a total hip arthroplasty. There was one traumatic injury to the obturator nerve and 2 patients were noted to have temporary weakness of the hip adductors postoperatively. CONCLUSION: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures in the elderly.

A randomised clinical trial comparing minimally invasive surgery to conventional approach for endoprosthesis in elderly patients with hip fractures.

BACKGROUND: In recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied in a randomised fashion. METHODS: This study is a prospective clinically randomised trial whose primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for endoprosthesis in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. 25 patients in the mini-incision surgery (MIS) group and 31 patients in the standard incision group (STD) were available for analysis. The following validated disease-specific outcome instruments were used: the Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life were assessed by the components of the Harris Hip Score (HHS) and SF-36. Radiographic outcomes were also evaluated as well as the rates of all reported complications and adverse events during the 2 years follow-up. RESULTS: There was no significant difference for operative time, blood losses, 72 h postoperative haemoglobin as well as the need for transfusion therapy between the two groups. Also, there was no difference between the groups for postoperative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using LEM and TUG did not demonstrate any statistically significant difference between mini- and standard incision. However, the HHS and the physical function component of the SF-36 were statistically better at 2 years in favour of the standard incision group. CONCLUSION: Based on the results of the present study, we cannot recommend the use of a minimally invasive approach over a standard approach in the implantation of a cemented endoprosthesis.

Lateral compression fractures of the superior pubic ramus with intra-articular extension.

A total of 30 patients with lateral compression fractures of the pelvis with intra-articular extension into the anterior column were followed for a mean of 4.2 years (2 to 6), using the validated functional outcome tools of the musculoskeletal function assessment and the short-form health survey (SF-36). The functional outcome was compared with that of a series of patients who had sustained type-B1 and type-C pelvic fractures. The lateral-compression group included 20 men and ten women with a mean age of 42.7 years (13 to 84) at the time of injury. Functional deficits were noted for the mental component summary score (p = 0.008) and in the social function domain (p < 0.05) of the SF-36. There was no evidence of degenerative arthritis in the lateral-compression group. However, they had high functional morbidity including greater emotional and psychological distress.

Quantitative assessment of articular cartilage and subchondral bone histology in the meniscectomized guinea pig model of osteoarthritis.

OBJECTIVE: A new image analysis system was employed to quantify the main histological parameters reflecting osteoarthritic features, at the cartilage and bone levels, in the meniscectomized guinea pig model of osteoarthritis (OA). METHODS: Meniscectomized (MNX) and sham-operated (SH) guinea pigs were studied 1 and 3 months after partial meniscectomy at the medial side of the left knee (n=10 to 12 animals/group). The left proximal tibias were included in methylmethacrylate. Sections were cut and stained with safranin O or Goldner trichrome. Parameters were quantified using special programs of a Biocom image analyser. The following parameters were evaluated at the medial side of the tibia: cartilage thickness (CT); fibrillation index (FI); proteoglycan content ratio based on safranin O staining intensities (PC); chondrocyte density (CD); bone volume (BV) and subchondral bone plate thickness (SBPT). The degree of user interaction varied from manually tracing objects to almost complete computer automation. RESULTS: Meniscectomy resulted in significant variations of these reproducible histomorphometric parameters both after 1 month (FI: +522%, P<0.01) and 3 months (FI: +162%, P<0.001; PC: -36.7%, P<0.001; CD: -31.8%, P<0.001; SBPT: +8.7%, P<0.05) post-operation (results expressed as percentage variation of MNX vs SH). The linear correlation analysis including data from SH and/or MNX animals at the two grouped time points revealed significant r values, in particular between cartilage (CT) and subchondral bone parameters (SBPT) (r=-0.41, P<0.01). CONCLUSIONS: Contrary to scoring evaluation, this system allowed to show the time-dependent impact of the pathology with an early fibrillation of the medial tibial cartilage appearing as soon as 1 month post-surgery, and the close relationship between bone and cartilage parameters during the progression of OA.

Steroid synthesis by equine conceptuses between days 7 and 14 and endometrial steroid metabolism.

The objective of this study was to determine if changes in steroid synthesis occurred in the horse blastocyst about the time of maternal recognition of pregnancy. Embryos collected between days 7.5 and 14.5 were incubated for 8 hr in vitro in HAM's F10 containing radiolabelled pregnenolone. The steroid metabolites in the incubation medium were separated by reverse phase HPLC and the major peaks expressed as a percentage of total metabolites. It was found that there were no major changes in the profile of metabolites throughout the period of study, although there was increased conversion as the conceptuses developed. It was found that the major metabolite produced was 17 alpha-hydroxyprogesterone and not estradiol as expected. A second experiment was conducted to determine if 17 alpha-hydroxyprogesterone was metabolized by endometrial tissue. Endometrial biopsies from anestrous mares and from pregnant and nonpregnant mares at day 11 were incubated with radiolabelled 17 alpha-hydroxyprogesterone, progesterone or pregnenolone. The 17 alpha-hydroxyprogesterone, but not progesterone nor pregnenolone, was converted to a more polar metabolite in all groups. Production of this metabolite was significant greater in the anestrous mares. This metabolite has not been unidentified conclusively. Thus, results of this study show that 17 alpha-hydroxyprogesterone is the major steroid synthesized by the equine blastocyst and that this steroid is further metabolized to an unidentified steroid by the endometrium. These steroids could play a role in conceptus development or maternal recognition of pregnancy.