Sex Differences in Complications Following Total Hip Arthroplasty: A Population-Based Study.

BACKGROUND: The relationship between sex and outcomes, especially complications, after total hip arthroplasty (THA) has not been well established. This study aimed to identify if patient biological sex significantly impacted complications after THA in Ontario, Canada. METHODS: A population-based retrospective cohort study of patients undergoing primary THA in Ontario from April 1, 2015 to March 31, 2020 was conducted. The primary outcome was major surgical complications within a year postsurgery (a composite of revision, deep infection requiring surgery, and dislocation). Secondary outcomes included the individual component of the composite primary outcome and major medical complications within 30 days. Proportional hazards regression calculated the adjusted hazards ratio for major surgical complications in men relative to women, adjusting for age, comorbidities, neighborhood income quintile, surgeon and hospital volume, and year of surgery. RESULTS: A total of 67,077 patients (median age 68 years; 54.1% women) from 61 hospitals were included; women were older with a higher prevalence of frailty. Women had a higher rate of major surgical complications within 1 year of surgery compared to men (2.9 versus 2.5%, adjusted odds ratio 1.19, 95% confidence interval 1.08 to 1.33, P = .0009). Conversely, men had a higher risk for medical complications within 30 days (6.3 versus 2.7%, P < .001). CONCLUSIONS: Observable sex disparities exist in post-THA complications; women face surgical complications predominantly, while medical complications are more prevalent in men. These insights can shape preoperative patient consultations. LEVEL OF EVIDENCE: Level III.

Association between immigration status and total knee arthroplasty outcomes in Ontario, Canada: a population-based matched cohort study.

BACKGROUND: Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients. METHODS: We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups. RESULTS: We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period (p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection (p < 0.001), death (p = 0.004), and surgical complications (p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation (p < 0.001) and less likely to present to the emergency department (p < 0.001) than Canadian-born patients. CONCLUSION: Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty.

Eliminating rote postoperative radiographs for surgically managed pediatric supracondylar humerus fractures.

BACKGROUND: Use of postoperative radiographs after surgical management of supracondylar humerus (SCH) fractures is often based on rote practice rather than evidence. The purpose of this study was to determine the frequency with which 3-week postoperative radiographs at the time of pin removal altered management plans in pediatric SCH fractures that were intraoperatively stable after closed reduction and percutaneous pinning (CRPP). METHODS: We prospectively recruited pediatric patients with SCH fractures managed by CRPP at our institution from June 2020 until June 2022, and reviewed retrospective data on pediatric SCH fractures managed surgically at our institution between April 2008 and March 2015. Patients were assessed for post-CRPP fracture alignment and stability. For prospective patients, we asked clinicians to document their management decision at the 3-week follow-up visit before evaluating the postoperative radiographs. Our primary outcome was change in management because of radiographic findings. RESULTS: Overall, 1066 patients in the retrospective data and 446 prospectively recruited patients met the inclusion criteria. In the prospective group, radiographic findings altered management for 2 patients (0.4%). One patient had slow callus formation and 1 patient was identified as having cubitus varus. Altered management included prolonged immobilization or additional radiographic follow-up. Radiographic findings altered management in 0 (0%) of 175 type II fractures, in 2 (0.9%) of 221 type III fractures, and in 0 (0%) of 44 type IV fractures. We obtained similar findings from retrospective data. CONCLUSION: Rote use of 3-week postoperative radiographs after surgical management of SCH fractures that are intraoperatively stable has minimal utility. Eliminating rote postoperative radiographs for SCH fractures can decrease the time and financial burdens on families and health care systems without affecting patient outcomes.

Virtual versus in-person physiotherapy following total knee arthroplasty: a comparative analysis.

PURPOSE: At our centre, we developed and implemented a video-based post-operative physiotherapy program for patients undergoing total knee arthroplasty (TKA). Our aims were to analyse and compare the outcomes of this program to in-person physiotherapy. METHODS: We reviewed the outcomes of 112 patients and captured range-of-motion (ROM) measurements and pain scores (P4 questionnaire). We compared the outcomes to a cohort of 175 patients undergoing in-person therapy. Comparative analysis was performed using a two-tailed Student's t-test. RESULTS: There was no significant difference between the two groups in age, sex, or initial post-operative knee ROM. On discharge from virtual physiotherapy, mean flexion was 122.6° (SD 7.6). There was no significant difference in improvement in knee flexion between the virtual and in-person groups (mean 30.6° vs 34.0°, p = 0.07). There was no significant difference in the proportion of patients achieving ≥ 120° of flexion (85.0% virtual vs 91.3% in-person, p = 0.11) or those achieving an extension deficit of ≤ 5° (96.0% vs 98.3%, p = 0.25). There was no difference in the number of PT visits to discharge (10.5 vs 11.1, p = 0.14) or final pain scores (12.4 vs 11.9, p = 0.61). CONCLUSION: Improvements in knee ROM measures are comparable between virtual and in-person physiotherapy with both groups achieving a good functional range. These findings have implications for the virtual delivery of healthcare, especially among remote populations and patients with mobility limitations.

Impact of the coronavirus disease 2019 pandemic on equity of access to hip and knee replacements: a population-level study.

PURPOSE: The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients. METHODS: Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID. RESULTS: A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease. CONCLUSION: The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.

MRI use leading up to total knee arthroplasty: a retrospective cohort study.

BACKGROUND: Demand for total knee arthroplasty (TKA) is increasing as it remains the gold-standard treatment for end-stage osteoarthritis (OA) of the knee. Magnetic resonance imaging (MRI) scans of the knee are not indicated for diagnosing knee OA and represent a possible delay to orthopaedic surgeon referral and unnecessary expenditure. The purpose of this study was to determine the proportion of patients who underwent an MRI in the two years prior to their primary TKA for OA and determine patient and physician associations with increased MRI usage. METHODS: This is a population-based cohort study using administrative data from Ontario, Canada. All patients over 40 years old who underwent their first primary TKA between April 1, 2008, and March 31, 2019, were included. Statistical analyses were performed using SAS and included the Cochran-Armitage test for trend of MRI prior to surgery. A predictive multivariable regression model was used to determine features correlated to receiving an MRI. RESULTS: There were 194,989 eligible first-time TKA recipients, of which 38,244 (19.6%) received an MRI in the two years prior to their surgery. The majority of these (69.6%) were ordered by primary care physicians. Patients who received an MRI were younger, had fewer comorbidities and were more affluent than patients who did not (p < 0.001). MRI use prior to TKA increased from 2008 to 2018 (p < 0.001). CONCLUSION: Despite MRIs rarely being indicated for the work-up of end-stage OA, nearly one in five patients have an MRI in the two years prior to their TKA. This may be increasing healthcare expenditure and surgical wait-times.

Basketball vs. Hockey-The Changing Face of Sport-Related Injuries in Canada.

OBJECTIVE: To characterize and compare the incidence of basketball-related, soccer-related, and hockey-related injuries over a 10-year period. DESIGN: Cohort analysis of sport-related injuries using multiple Ontario healthcare databases. SETTING: Emergency department visits in Ontario, Canada. PATIENTS: Any patient who sustained musculoskeletal injuries sustained while playing basketball, soccer, or hockey between 2006 and 2017 were identified. ASSESSMENT OF RISK FACTORS: Sport of injury, age, sex, rurality index, marginalization status, and comorbidity score. MAIN OUTCOME MEASURES: Annual Incidence Density Rates of injury were calculated for each sport, and significance of trends was analyzed by assessing overlap of 95% confidence intervals. RESULTS: One lakhs eighty five thousand eighty hundred sixty-eight patients (median age: 16 years, interquartile range 13-26) received treatment for sport-related injuries (basketball = 55 468; soccer = 67 021; and hockey = 63 379). The incidence of basketball-related and soccer-related injuries increased from 3.4 (3.3-3.5) to 5.6 (5.5-5.7) and 4.4 (4.3-4.5) to 4.9 (4.8-5) per 10 000 person years, respectively, whereas the incidence of hockey-related injuries decreased from 4.7 (4.6-4.8) to 3.7 (3.6-3.8). Patients with basketball injuries were more marginalized (3.01 ± 0.74) compared with patients with soccer and hockey injuries (2.90 ± 0.75 and 2.72 ± 0.69, respectively). CONCLUSIONS: Accurate regional epidemiologic information regarding sports injuries can be used to guide policy development for municipal planning and sport program development. The trends and demographic patterns described highlight general and sport-specific injury patterns in Ontario. Populations with the highest incidence of injury, most notably adolescents and men older than 50, may represent an appropriate population for injury risk prevention.

The Use of Rifampin in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Comparative Studies.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty (TJA). Rifampin is an antibiotic with the ability to penetrate bacterial biofilms, and thus has been considered as a potentially important adjunct in the prevention and treatment of PJI. The aim of this systematic review is to evaluate and summarize the use of rifampin in TJA, particularly in the context of PJI. METHODS: A literature search of all relevant electronic databases was performed. All comparative studies assessing the use of rifampin in the context of TJA were included. Descriptive data are reported, and a meta-analysis was performed using all studies which compared the addition of rifampin to standard care in treating PJI. RESULTS: A total of 33 studies met inclusion criteria. A meta-analysis of 22 studies comparing the addition of rifampin to standard care for treating PJI found a significant reduction in failure rates (26.0% vs 35.9%; odds ratio 0.61, 95% confidence interval 0.43-0.86). The protective effect of rifampin was maintained in studies which included exchange arthroplasty as a treatment strategy, but not in studies only using an implant retention strategy. Among studies reporting adverse events of rifampin, there was a 20.5% adverse event rate. CONCLUSION: Overall, rifampin appears to confer a protective effect against treatment failure following PJI. This treatment effect is particularly pronounced in the context of exchange arthroplasty. Further high-level evidence is needed to clarify the exact indications and doses of rifampin which can most effectively act as an adjunct in the treatment of PJI. LEVEL OF EVIDENCE: Level III, Systematic Review and Meta-Analysis of Level I-III Studies.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis.

BACKGROUND: Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. METHODS: This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. RESULTS: The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was - 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours - 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. CONCLUSIONS: We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

The Association Between Surgeon Age and Early Surgical Complications of Elective Total Hip Arthroplasty: Propensity-Matched Cohort Study (122,043 Patients).

BACKGROUND: The aim of this study was to examine the relationship between surgeon age and early surgical complications following primary total hip arthroplasty (THA), within a year, in Ontario, Canada. METHODS: In a propensity-matched cohort, we defined consecutive adults who received their first primary THA for osteoarthritis (2002-2018). We obtained hospital discharge abstracts, patient's demographics and physician claims. Age of the primary surgeon was determined for each procedure and used as a continuous variable for spline analysis, and as a categorical variable for subsequent matching (young <45; middle-age 45-55; older >55). The primary outcome was early surgical complications (revision, dislocation, infection). Secondary analyses included high-volume vs low-volume surgeons (≤35 THA per year). RESULTS: We identified 122,043 THA recipients, 298 surgeons with median age 49 years. Younger, middle-aged, and older surgeons performed 39%, 29%, and 32% THAs, respectively. Middle-aged surgeons had the lowest rate of complications. Younger surgeons had a higher risk of composite complications (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.09-1.44, P = .002), revision (OR 1.28, 95% CI 1.07-1.54, P = .007), and infection (OR 1.39, 95% CI 1.12-1.71, P = .003). Older surgeons also had higher risk for composite complications (OR 1.18, 95% CI 1.03-1.36, P = .019), revision (OR 1.33, 95% CI 1.10-1.62, P = .004), and dislocation (OR 1.37, 95% CI 1.08-1.73, P = .009). However, when excluding low-volume surgeons, older high-volume surgeons had similar complications to middle-aged surgeons. CONCLUSION: Younger surgeons (<45 years) had the highest recorded complications rate while the lowest rate was for surgeons aged 45-55. Volume rather than age was more important in determining rate of complications of older surgeons. LEVEL OF EVIDENCE: IV.

Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients.

BACKGROUND: The aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m2). METHODS: Population-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery). RESULTS: A total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications. CONCLUSION: Patients' large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.

Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty.

Importance: Controversy exists about the preferred surgical approach for total hip arthroplasty (THA). Objective: To determine whether an anterior approach is associated with lower risk of complications than either a lateral or posterior approach. Design, Setting, and Participants: Population-based retrospective cohort study of all adults in Ontario, Canada, who had undergone primary THA for osteoarthritis between April 1, 2015, and March 31, 2018. All patients were followed up over a 1-year period (study end date, March 31, 2019). Exposures: Surgical approach (anterior vs lateral/posterior) for THA. Main Outcomes and Measures: Major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, or revision surgery). Outcomes were compared among propensity-score matched groups using Cox proportional hazards regression. Results: Of the 30 098 patients (mean [SD] age, 67 years [10.7 years]; 16 079 women [53.4%]) who underwent THA, 2995 (10%) underwent the anterior approach; 21 248 (70%), the lateral approach; and 5855 (20%) the posterior approach performed at 1 of 73 hospitals by 1 of 298 surgeons. All patients were followed up for 1 year. Compared with those undergoing the lateral or posterior approach, patients undergoing an anterior approach were younger (mean age, 65 vs 67 years; standardized difference, 0.17); had lower rates of morbid obesity (4.8% vs 7.6%; standardized difference, 0.12), diabetes (14.2% vs 19.9%; standardized difference, 0.15), and hypertension (53.4% vs 62.9%; standardized difference, 0.19); and were treated by higher-volume surgeons (median range, 111 procedures; interquartile range, 69-172 vs 77 procedures, interquartile range, 50-119 in the prior year; standardized difference, 0.55). Compared with 2993 propensity-score matched patients undergoing a lateral or posterior approach, the 2993 matched patients undergoing anterior approaches had a significantly greater risk of a major surgical complication (61 patients [2%] vs 29 patients [1%]; absolute risk difference, 1.07%; 95% CI, 0.46%-1.69%; hazard ratio, 2.07; 95% CI, 1.48 to 2.88). Conclusions and Relevance: Among patients undergoing total hip arthroplasty, an anterior surgical approach compared with a posterior or lateral surgical approach was associated with a small but statistically significant increased risk of major surgical complications. The findings may help inform decisions about surgical approach for hip arthroplasty, although further research is needed to understand pain and functional outcomes.

Complications of type II supracondylar humerus fractures treated at a specialized paediatric centre.

BACKGROUND: Supracondylar humerus (SCH) fractures are the most common operatively treated paediatric fracture in Canada. Previous literature describing the low-energy (Gartland type II) subtype reports varying complication rates from a variety of practice settings. We sought to examine complications of type II SCH fractures treated at a Canadian specialized paediatric centre. METHODS: We conducted a retrospective cohort study of patients aged 0 to 14 admitted to SickKids, Toronto, Ontario for surgical treatment of a type II SCH fracture from 2008 to 2015. The primary outcome of this study was relevant perioperative complications including: open fracture, compartment syndrome, pre- and postoperative vascular compromise, pre- and postoperative neurological compromise, failure to obtain a closed reduction (i.e., open reduction), postoperative infection, and reoperation within 3 months. RESULTS: There were 370 patients included in the study with mean (standard deviation) age 5.14 years (±2.51). The overall rate of relevant complications in the study cohort was 3.6% (13/358, 12 missing), with 12 cases of nerve palsy (3.3%; 2 iatrogenic [0.6%]) that resolved by final follow-up and one case of preoperative nerve palsy (0.3%) that did not. Importantly, there were no cases of vascular compromise, open fracture, compartment syndrome, or infection. DISCUSSION AND CONCLUSION: Complications associated with type II SCH fractures managed at a specialized paediatric centre that result in long-term morbidity are extremely rare (0.3%). Perioperative inpatient monitoring for patients with these fractures may not be justified based on these data. Prospective studies are required to confirm safety, evaluate patient perspectives, and demonstrate cost savings of outpatient surgical management.

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 utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study.

PURPOSE: Flexible bronchoscopy with bronchoalveolar lavage (BAL) is commonly performed in immunocompromised patients. Nevertheless, it remains unclear whether bronchoscopy with BAL leads to changes in medical management or is associated with procedural complications among critically ill acute leukemia (AL) patients. METHODS: We evaluated 71 AL patients who underwent diagnostic bronchoscopy with BAL in the intensive care unit (ICU) between 1 January 2007 and 31 December 2012. We recorded baseline characteristics, vital signs (before, during, and after the procedure), changes in medical management following the procedure, and procedural complications. Using a multivariable logistic regression model, we explored the relationship between patient characteristics and whether bronchoscopy changed management or caused complications. Patient characteristics included as predictors in the regression model were age, sex, immunosuppression status (those undergoing active chemotherapy), and the Acute Physiology And Chronic Health Evaluation II score. RESULTS: The most common indication for ICU admission was respiratory failure (51 patients, 72%), followed by sepsis (14 patients, 20%). Overall, the results obtained from bronchoscopy with BAL were associated with a change in management in 32 patients (45%), most commonly a change in antimicrobial therapy as a result of an infectious pathogen being identified (17 patients, 24%). Complications were documented in nine patients (13%) and included post-procedural hypoxia (six patients, 8%), the need for intubation (one patient, 9% of non-intubated patients), and tracheal perforation (one patient, 1%). No clinically significant changes in patient vital signs were observed during or immediately following the procedure. Patient characteristics did not predict whether bronchoscopy was associated with changes in medical management or procedural complications in multivariable analyses. CONCLUSIONS: Flexible bronchoscopy with BAL is relatively safe and helps to guide medical management among patients with AL admitted to the ICU.

Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada.

BACKGROUND: The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures may safely reduce the number of radiographs and follow-up assessments for children with these injuries. The study objective was to examine potential cost-savings of the SKPOP from the perspective of the Ministry of Health and Long-term Care (MOHLTC). METHODS: Two sets of resource profiles, based on direct health care costs were created for a cohort of patients treated at our institution: the first based on actual follow-up assessment values, and the other based on follow-up assessments according to the SKPOP. Differences between the two profiles represent potential cost-savings. A decision-analysis and associated probabilistic sensitivity analysis (PSA) were performed. RESULTS: In a cohort of 239 patients treated between 2009 and 2014, 92.9% (222) would have met SKPOP eligibility. Management according to this pathway would have reduced orthopaedic assessments and shoulder radiograph series by 83.6% (470/562) and 70.8% (367/589), respectively. For the cohort examined, a potential cost-savings of $30,040.56 ($135.32/patient) was observed. A PSA, accounting for variable SKPOP adherence and health care utilization, yielded cost-savings in 96.5% of the iterations run through the decision-analysis model and an average cost-savings of $57.82/patient. Based on these results and the annual provincial incidence rate of eligible patients (n=575), the MOHLTC could potentially save $33,249.45 annually with province-wide implementation. CONCLUSIONS: Implementation of the SKPOP for a cohort of patients managed at our institution could have resulted in cost-savings due to substantial reductions in health care utilization. Cost-savings are likely to occur with provincial implementation of the SKPOP for proximal humerus fractures.

Timing of femoral shaft fracture fixation following major trauma: A retrospective cohort study of United States trauma centers.

BACKGROUND: Femoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level. METHODS AND FINDINGS: A retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012-2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation. We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range [IQR] 9-22). Median time to fixation was 15 hours (IQR 7-24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio [RR] 2.0; 95% CI 1.2-3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1-1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0-2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors. CONCLUSIONS: In this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of femoral shaft fractures, which could not be explained by differences in patient case mix. Patients treated at centers where delayed fixation was most common were at significantly greater risk of pulmonary embolism and required longer hospital stay. Trauma centers should strive to minimize delays in fixation, and quality improvement initiatives should emphasize this recommendation in best practice guidelines.

Direct medical costs of motorcycle crashes in Ontario.

BACKGROUND: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. METHODS: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. RESULTS: We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). INTERPRETATION: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety.