Fragility fracture patients with a history of prior fractures more likely to present with multiple risk factors: findings from a province-wide fracture liaison service.

We examined the demographic characteristics and risk factors of FLS fragility fracture patients who had sustained prior fragility fracture(s) and found that this is an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle. PURPOSE: Our primary objective was to examine whether fragility fracture patients presenting to a provincial fracture liaison service (FLS) having a history of prior fractures, versus those without, differ in demographic characteristics and risk factors for future fracture. A secondary objective was to understand if those who report two or more prior fractures differ from those reporting one prior fracture. METHODS: This cohort study included fragility fracture patients aged 50 + enrolled in the Ontario FLS between July 2017 and September 2019. Patients with versus those without prior fractures were compared on age, sex, index fracture site, biological parents' history of hip fracture, current fracture due to a fall, history of feeling unsteady when walking, history of falls in the past year, smoking, oral steroid use, and comorbid chronic conditions. Pearson's chi-square, Fischer's exact, and analysis of variance tests were used to assess differences. RESULTS: Among 14,454 patients, 16.8% (n = 2428) reported a history of one or more prior fractures after the age of 40. They were significantly more likely to be older, female, with a higher number of comorbidities, with greater incidence of falls, and feel unsteady when walking. Compared to those with one prior fracture, patients with greater than one prior fracture were more likely to report falls in the past year and feel unsteady when walking. CONCLUSION: Findings suggest that FLS fragility fracture patients who had sustained prior fragility fracture are an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service.

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group. PURPOSE: To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up. METHODS: This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening. RESULTS: Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males. CONCLUSIONS: Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

Equal treatment: no evidence of gender inequity in osteoporosis management in a coordinator-based fragility fracture screening program.

We evaluated gender imbalance in osteoporosis management in a provincial coordinator-based fracture prevention program and found no difference by gender in treatment of high-risk fragility fracture patients. This establishes that a systemic approach with interventions for all fragility fracture patients can eliminate the gender inequity that is often observed. INRODUCTION: The purpose of this study was to evaluate an Ontario-based fracture prevention program for its ability to address the well-documented gender imbalance in osteoporosis (OP) management, by incorporating its integrated fracture risk assessments within a needs-based evaluation of equity. METHODS: Fragility fracture patients (≥ 50 years) who were treatment naïve at screening and completed follow-up within 6 months of screening were studied. Patients who underwent bone mineral density (BMD) testing done in the year prior to their current fracture were excluded. All participants had BMD testing conducted through the Ontario OP Strategy Fracture Screening and Prevention program, thus providing us with fracture risk assessment data. Our primary study outcome was treatment initiation at follow-up within 6 months of screening. Gender differences were compared using Fisher's exact test, at p < 0.05. RESULTS: After adjusting for subsequent fracture risk, study participants did not show a statistically significant gender difference in pharmacotherapy initiation at follow-up (p > 0.05). 68.4% of women and 66.2% of men at high risk were treated within 6 months of screening. CONCLUSION: Needs-based analyses show no difference by gender in treatment of high-risk fragility fracture patients. An intensive coordinator-based fracture prevention model adopted in Ontario, Canada was not associated with gender inequity in OP treatment of fragility fracture patients after fracture risk adjustment.

Addition of a fracture risk assessment to a coordinator's role improved treatment rates within 6 months of screening in a fragility fracture screening program.

We evaluated the impact of a more intensive version of an existing post-fracture coordinator-based fracture prevention program and found that the addition of a full-risk assessment improved treatment rates. These findings provide additional support for more intensive programs aimed at reducing the risk of re-fractures. INTRODUCTION: Evidence-based guidelines support coordinator-based programs to improve post-fracture osteoporosis guideline uptake, with more intensive programs including bone mineral density (BMD) testing and/or treatment being associated with better patient outcomes. The purpose of this study was to evaluate the impact of a more intensive version (BMD "fast track") of an existing provincial coordinator-based program. METHODS: We compared two versions of the program that screened treatment naïve fragility fracture patients (>50 years). Cases came from the BMD fast track program that included full fracture risk assessment and communication of relevant guidelines to the primary care provider (PCP). Matched controls were selected from the usual care program matching according to age, sex, fracture type, and date. Two matching techniques were used: traditional (hard) matching (TM) and propensity score matching (PS). The outcomes were treatment initiation with bone sparing medication, BMD testing rate, and the rate of returning to discuss the test results with a PCP. RESULTS: The program improvements led to a significant improvement in treatment initiation within 6 months from 16 % (controls based on PS) or 21 % (controls based on TM) to 32 % (cases). Ninety percent of patients in the BMD fast track program returned to their PCP to discuss bone health in the cases versus 60 % of the controls (for TM and PS). BMD testing occurred in 96 % of cases compared to the 66 (TM) or 65 % (PS) of the matched controls. CONCLUSIONS: Addition of a full-risk assessment to a coordinator-based program significantly improved treatment rates within 6 months of screening.

Patient acceptance of osteoporosis treatment: Application of the stages of change model.

OBJECTIVES: To examine whether a commonly used model of behaviour change, stages of change, is helpful in understanding osteoporosis treatment initiation in a cohort of fragility fracture patients. STUDY DESIGN: This longitudinal cohort study used data from a provincial osteoporosis screening program targeting fragility fracture patients age 50 and over. Logistic regression was used to identify baseline factors associated with patients moving from the first, pre-contemplation stage at baseline to the more advanced stages of action/maintenance at follow-up, when treatment is initiated and maintained. MAIN OUTCOME MEASURE: Patient's stage-of-change readiness to accept osteoporosis treatment. RESULTS: At baseline, 91% of patients were in the pre-contemplation stage. Of these, 74.1% remained at the same stage at follow-up, 2.7% moved to contemplation and preparation while 23.2% moved to action/maintenance. The adjusted analysis showed that those who moved from pre-contemplation to action/maintenance were more likely to have a previous fracture OR 1.5 (1.1-2.0), history of oral steroid use OR 2.1 (1.3-3.5), higher perceived benefits to osteoporosis drug treatment OR 1.2 (1.0-1.3), perception of bones as "thin" OR 2.8 (2.0-4.0) and were less likely to perceive that they were taking too many medications OR 0.6 (0.5-0.9). CONCLUSIONS: With the majority of patients in the pre-contemplation and the action/maintenance stages, our results suggest an existence of a two-stage model. The baseline factors that we identified can be used to predict which patients are less likely to initiate treatment, which in turn, can be used to inform post-fracture interventions and facilitate behaviour change.

Factors influencing the pharmacological management of osteoporosis after fragility fracture: results from the Ontario Osteoporosis Strategy's fracture clinic screening program.

UNLABELLED: Potential mediating factors in the pathway to initiation of osteoporosis treatment following a fragility fracture were evaluated. Patients' perceived need for treatment, mediated by their perception of bone density test results, was central to treatment initiation. Interventions focusing on patients' perceptions of need and test results may improve treatment rates. INTRODUCTION: We tested a hypothesized pathway to osteoporosis (OP) pharmacotherapy initiation in fragility fracture patients. We hypothesized that bone mineral density (BMD) testing is strongly associated with treatment initiation and perception of BMD test results would inform patients' perceived need for treatment, which would mediate the effect between BMD testing and treatment initiation. METHODS: A longitudinal cohort study followed patients, ≥50 years of age, screened for fragility fracture in 31 fracture clinics in Ontario, Canada who had no prior diagnosis of or treatment for OP. At screening, OP risk factors, baseline-patient perception of OP risk, OP knowledge, and perceived benefits of medication were reported by patients. Patients were followed up within 6 months of fracture to determine BMD testing and prescription of and adherence to first-line OP pharmacotherapy. Structural equation modeling tested the hypothesized pathway. Significance and magnitude of the coefficients and indicators of overall model fit were used to test our model. RESULTS: The direct path from BMD testing to OP treatment initiation was non-significant. The pathway to treatment initiation was mediated by patients' perception of their need, which was influenced by their self-reported BMD results. Baseline fracture risk factors, knowledge of OP, and perceived benefits of treatment-predicted patient-perceived need for treatment at follow-up and initiation of OP treatment. CONCLUSIONS: Patient perceptions were central factors in the path to initiation of OP pharmacotherapy. Interventions to facilitate accurate patient perceptions of BMD test results and OP risk status could prove helpful in improving OP treatment initiation.

Coordinator-based systems for secondary prevention in fragility fracture patients.

The underlying causes of incident fractures--bone fragility and the tendency to fall--remain under-diagnosed and under-treated. This care gap in secondary prevention must be addressed to minimise both the debilitating consequences of subsequent fractures for patients and the associated economic burden to healthcare systems. Clinical systems aimed at ensuring appropriate management of patients following fracture have been developed around the world. A systematic review of the literature showed that 65% of systems reported include a dedicated coordinator who acts as the link between the orthopaedic team, the osteoporosis and falls services, the patient and the primary care physician. Coordinator-based systems facilitate bone mineral density testing, osteoporosis education and care in patients following a fragility fracture and have been shown to be cost-saving. Other success factors included a fracture registry and a database to monitor the care provided to the fracture patient. Implementation of such a system requires an audit of existing arrangements, creation of a network of healthcare professionals with clearly defined roles and the identification of a 'medical champion' to lead the project. A business case is needed to acquire the necessary funding. Incremental, achievable targets should be identified. Clinical pathways should be supported by evidence-based recommendations from national or regional guidelines. Endorsement of the proposed model within national healthcare policies and advocacy programmes can achieve alignment of the objectives of policy makers, professionals and patients. Successful transformation of care relies upon consensus amongst all participants in the multi-disciplinary team that cares for fragility fracture patients.

Biomechanical validation of finite element models for two silicone metacarpophalangeal joint implants.

Silicone implants are used for prosthetic arthroplasty of metacarpophalangeal (MCP) joints severely damaged by rheumatoid arthritis. Different silicone elastomer MCP implant designs have been developed, including the Swanson and the NeuFlex implants. The goal of this study was to compare the in vitro mechanical behavior of Swanson and NeuFlex MCP joint implants. Three-dimensional (3D) finite element (FE) models of the silicone implants were modeled using the commercial software ANSYS and subjected to angular displacement from 0 deg to 90 deg. FE models were validated using mechanical tests of implants incrementally bent from 0 deg to 90 deg in a joint simulator. Swanson size 2 and 4 implants were compared with NeuFlex size 10 and 30 implants, respectively. Good agreement was observed throughout the range of motion for the flexion bending moment derived from 3D FE models and mechanical tests. From 30 deg to 90 deg, the Swanson 2 demonstrated a greater resistance to deformation than the NeuFlex 10 and required a greater bending moment for joint flexion. For larger implant sizes, the NeuFlex 30 had a steeper moment-displacement curve, but required a lower moment than the Swanson 4, due to implant preflexion. On average, the stress generated at the implant hinge from 30 deg to 90 deg was lower in the NeuFlex than in the Swanson. On average, starting from the neutral position of 30 deg for the preflexed NeuFlex implant, higher moments were required to extend the NeuFlex implants to 0 deg compared with the Swanson implants, which returned spontaneously to resting position. Implant toggling within the medullary canals was less in the NeuFlex than in the Swanson. The differential performance of these implants may be useful in implant selection based on the preoperative condition(s) of the joint and specific patient functional needs.

A program with a dedicated coordinator improved chart documentation of osteoporosis after fragility fracture.

UNLABELLED: Post-fracture osteoporosis care is becoming recognized as essential by the orthopaedic community, but programs and systems are needed to ensure that this care is routinely provided. Chart documentation related to OP, which is valuable for continuity of care, increased significantly following establishment of an osteoporosis program with a dedicated coordinator. INTRODUCTION: Post-fracture osteoporosis (OP) care has been repeatedly reported to be inadequate. Through a coordinator-based program, we addressed OP care for more than 95% of fragility fracture patients (1), but we do not know if documentation by orthopaedic surgeons improved. The literature suggests that chart documentation, though underestimating true care, is an indicator of the salient aspects of a condition. Thus chart documentation could be used to reflect an emerging recognition of OP as an important issue to be addressed in the orthopaedic management of the fragility fracture. The purpose of this study was to evaluate if there was an increased documentation of OP by orthopaedic surgeons before and after introduction of a coordinator-based program where the coordinator was known to address OP in 95% of cases. METHODS: Chart audits were conducted to quantify OP documentation for patients treated after program initiation compared with age-, sex-, and fracture type-matched controls who presented prior to program implementation. Documentation rates were compared using chi(2) tests. Multivariable logistic regression analyses were performed to identify patient characteristics associated with OP-related documentation. RESULTS: After program implementation, chart documentation of OP diagnosis (unadjusted OR 2.2, 95% CI 1.1-4.4), of referral for OP follow-up (unadjusted OR 3.1, 95% CI 1.5-6.1), and of initiation of OP management (unadjusted OR 8.2, 95% CI 4.0-16.5) by orthopaedic surgeons was more likely. Being in the post-implementation group was stronger than any patient factors in predicting OP charting. CONCLUSIONS: Physicians working in a clinic with a coordinator-based OP program were more likely to document OP-related care in patients' medical charts. We believe this in turn reflected increased attention to OP by physicians in the orthopaedic management of fragility fractures.

Development of an integrated-care delivery model for post-fracture care in Ontario, Canada.

INTRODUCTION: The purpose of this study was to develop an integrated-care model for patients at highest risk for osteoporosis, those with a low-trauma fracture. Specific objectives were to describe the current processes and patterns of post-fracture care in hospitals in Ontario; to examine health-care professional and patient awareness of osteoporosis and the roles and responsibilities of various organizations and health care professionals; and to identify barriers and facilitators and obtain feedback on the model. METHODS: In 2002, questionnaires were completed for 178 eligible hospitals. RESULTS: Only 65% of hospitals inform primary-care physicians of a fracture for all patients and only 4% indicated that they provide information about osteoporosis. The main themes that emerged from the four patient focus groups (n=21) were lack of continuity of care, the absence of a link between the fracture and osteoporosis by both patients and health care providers, and need for information. Most participants agreed that something was needed to prompt their primary-care physician to investigate for osteoporosis. The four physician focus groups (n=26) identified a role for orthopaedic surgeons to flag cases. CONCLUSIONS: From 34 key informant interviews with community-based organizations, we found a lack of integration between health care professionals who provide fracture care and those who provide osteoporosis management and fall prevention. Based on these data, we developed an integrated local-resource-based post-fracture care model, which we obtained feedback on at a stakeholder consultation workshop. The model focuses on improving emergency department/fracture clinic communication, emphasizes the need for follow-up investigation by family physicians for osteoporosis, and incorporates other health care professionals and a telemedicine multidisciplinary osteoporosis clinic. We are currently evaluating whether this model leads to an increase in appropriate investigation of and treatment for osteoporosis in patients with low-trauma fractures.

Surgery of the hand in severe systemic sclerosis.

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5-9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint excisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed "finger-in-palm" deformities. Lesions of cutaneous calcinosis were removed in four patients. Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of nonunion. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.

Assessing damage in individual joints in rheumatoid arthritis: a new method based on the Larsen system.

OBJECTIVES: To evaluate observer agreement using the Larsen system (LS) and a Modified Larsen system (ML) when assessing individual joints of the hands and wrists in rheumatoid arthritis, and to compare the two systems. To determine the minimally important difference (MID) for the ML. METHODS: Thirty radiographs of hands and wrists from 10 patients who presented with RA were graded by two blinded observers, using the LS and then the ML. Patients were followed for a mean of 7.2 years (range: 4-10 years). Inter- and intra-observer agreement were calculated using the kappa statistic with linear incremental weights. Inter-observer agreement was also computed for the summed score, using an intraclass correlation coefficient. Inter-observer error was estimated by calculating the mean and standard deviation of the grading differences between the two observers. Prevalence of damage was calculated as a ratio of damage: no damage and expressed as a percentage. Pairs of radiographs were comparatively graded using a seven-point Likert scale. RESULTS: The kappa statistic for inter-observer agreement was 0.38 (marginal reproducibility) for the LS and 0.52 (good reproducibility) for the ML (P = 0.004). Using a difference of one grade as perfect agreement, it was 0.56 (good reproducibility) for the LS and 0.87 (excellent reproducibility) for the ML (P = 0.001). Intra-observer agreement was high in both systems. The distribution of ML-grade differences varied according to the level of the Likert scale: for "a little bit worse", representing the smallest amount of detectable damage progression, the distribution differences peaked around two grades. This value represented a MID 87% of the time. CONCLUSIONS: The LS lacks precision for individual joints. The ML, it is proposed, has more detailed definitions of grades, and is more reliable. When pairs of radiographs were compared, a two-grade difference on the ML was the MID.

Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review.

Fragility fractures are a strong indicator of underlying osteoporosis (OP). With the risk of future fracture being increased 1.5- to 9.5-fold following a fragility fracture, the diagnosis and treatment of OP in men and women with fragility fractures provides the opportunity to prevent future fragility fractures. This review describes the current status of practice in investigation and diagnosis of OP in men and women with fragility fractures, the rates and types of postfracture treatment in patients with fragility fractures and OP, interventions undertaken in this population, and the barriers to OP identification and treatment. A literature search performed in Medline, Healthstar, CINAHL, EMBASE, PreMedline, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 37 studies on OP diagnosis, treatment, and interventions. The studies varied in design methodology, study facilities, types of fractures, and pharmacological treatments. Some studies revealed that no patients with fragility fractures received investigation or treatment for underlying OP. Investigation of OP by bone mineral density was low: 14 of 16 studies reported investigation of less than 32% of patients. Investigation by bone mineral density resulted in high rates of OP diagnosis (35-100%), but only moderate use of calcium and vitamin D (8-62%, median 18%) and bisphosphates (0.5-38%) in patients investigated postfracture. Studies on barriers to OP identification and treatment focused on various groups of health practitioners. Barriers included the cost of therapies, time and cost of resources for diagnosis, concerns about medications, and the lack of clarity regarding the responsibility to undertake this care.

Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis.

BACKGROUND: Osteoarthritis (OA) of the hip is a progressive condition that has no cure and often requires a total hip arthroplasty (THA). The principal methods for THA are the posterior and direct lateral approaches. The posterior approach is considered to be easy to perform, however, increased rates of dislocation have been reported. The direct lateral approach facilitates cup positioning which may decrease rates of hip dislocation and diminishes the risk of injury to the sciatic nerve. However, there is an increased risk of limp. Dislocation of a hip prosthesis is a clinically important complication after THA, in terms of morbidity implications and costs. OBJECTIVES: To determine the risks of prosthesis dislocation, postoperative Trendelenburg gait and sciatic nerve palsy after a posterior approach, compared to a direct lateral approach, for adult patients undergoing THA for primary OA. SEARCH STRATEGY: MEDLINE, EMBASE, CINHAL and Cochrane databases were searched until 2002. No language restrictions were applied. SELECTION CRITERIA: Published trials comparing posterior and direct lateral surgical approaches to THA in participants 18 years and older with a diagnosis of primary hip OA. DATA COLLECTION AND ANALYSIS: Retrieved articles were assessed independently by the two reviewers for their methodological quality. MAIN RESULTS: Four prospective cohort studies involving 241 participants met the inclusion criteria. The primary outcome, dislocation, was reported in two studies. No significant difference between posterior and direct lateral surgical approach was found [1/77 (1.3%) versus 3/72 (4.2%); relative risk (RR) 0.35; 95% confidence intervals (CI) 0.04 to 3.22]. The presence of postoperative Trendelenburg gait was not significantly different between these surgical approaches. The risk of nerve palsy or injury was significantly higher among the direct lateral approaches [1/43 (2%) versus 10/49 (20%); RR 0.16, 95% CI 0.03 to 0.83]. However, there were no significant differences when comparing this risk nerve by nerve for both approaches, in particular for the sciatic nerve. Of the other outcomes considered only the average range of internal rotation in extension of the hip was significantly higher (weighted mean difference 16 degrees, 95% CI 8 to 23) in the posterior approach group (mean 35 degrees, standard deviation 13 degrees ) compared to the direct lateral approach (mean 19 degrees, standard deviation 13 degrees ). REVIEWER'S CONCLUSIONS: The quality and quantity of information extracted from the trials performed to date are insufficient to make any firm conclusion on the optimum choice of surgical approach in adult patients undergoing primary THA for OA.

High frequency acoustic parameters of human and bovine articular cartilage following experimentally-induced matrix degradation.

Matrix degradation and proteoglycan loss in articular cartilag eare features of early osteoarthritis. To determine the effect of matrix degradation and proteoglycan loss on ultrasound propagation in cartilage, we used papain and interleukin-1alpha to degrade the matrix proteoglycans of human and bovine cartilage samples, respectively. There is also minor collagen alteration associated with these chemical degradation methods. We compared the speed of sound and frequency dependent attenuation (20-40 MHz) of control and experimental paired samples. We found that a loss of matrix proteoglycans and collagen disruption resulted in a 20-30% increase in the frequency dependent attenuation and a 2% decrease in the speed of sound in both human and bovine cartilage. We conclude that the frequency dependent attenuation and speed of sound in articular cartilage are sensitive to experimental modification of the matrix proteoglycans and collagen. These findings suggest that ultrasound can potentially be used to detect morphologic changes in articular cartilage associated with the progression of osteoarthritis.

Changes in cross-sectional geometry of the distal femoral metaphysis associated with inflammatory arthritis are reduced by a bisphosphonate (zoledronate).

An increased risk of fracture is a feature of rheumatoid arthritis and of animal models of inflammatory arthritis. We examined geometrical changes in the metaphyseal cortex of the distal femur in an animal model of inflammatory arthritis. Additionally, we examined the effect of a bisphosphonate in preventing these changes. Five groups of rabbits were studied: normal controls, those with inflammatory arthritis, and three groups with arthritis treated with bisphosphonate. To determine geometrical properties, image analysis was performed on digitized cross sections of the femoral metaphyseal cortices. The results demonstrated that the posterior cortical wall was significantly less thick in rabbits with arthritis than in normal rabbits and in the rabbits in the three bisphosphonate treatment groups (p < 0.05). Moment of inertia about the lateral-medial axis was reduced in rabbits with arthritis compared with normal rabbits (p < 0.05). Cross-sectional area was not significantly different between groups. The changes suggest a mechanism of weakening of bone in arthritis; when the results are coupled with results of previous porosity studies, severe directional weakness is apparent. Bisphosphonate was effective in preserving bone integrity in inflammatory arthritis.

Improving patient satisfaction with time spent in an orthopedic outpatient clinic.

OBJECTIVE: To determine if patient satisfaction can be improved by changing patients' expectations of the clinic visit and by decreasing the total time spent in the clinic. DESIGN: A prospective comparative analysis carried out in 4 phases. SETTING: An university-affiliated orthopedic outpatient clinic. PATIENTS: All patients seen in the orthopedic outpatient clinic were eligible. Phase 1 determined the total clinic time required by patient type; phase 2 assessed baseline satisfaction; phase 3 altered patients' expectations; and phase 4 altered patients' expectations and scheduled visits by patient type. INTERVENTION: Patient questionnaires. MAIN OUTCOME MEASURE: Patient satisfaction with time spent in the clinic. RESULTS: Of 708 distributed questionnaires, 622 (88%) were completed (547 totally complete, 75 partially complete). Total time spent in the clinic decreased across phases 2, 3 and 4 (mean 99.2, 94.7 and 85.2 minutes, respectively, but was significantly different only between phases 3 and 4; p = 0.05, Duncan's multiple range test). The percentage of patients who rated their waiting time as "excellent" increased across phases 2, 3 and 4 (14.6%, 18.8% and 31.1%, respectively; p = 0.0004, chi 2 test). CONCLUSION: Patient satisfaction can be improved by altering patient expectations and by decreasing the total time spent in clinic.

Investigation and treatment of osteoporosis in patients with fragility fractures.

BACKGROUND: Many patients who have undiagnosed osteoporosis and a recent fragility fracture present to fracture clinics in Canadian hospitals, where the focus of management is on fracture care. The rate of diagnosis and treatment of osteoporosis in this patient group is unknown. METHODS: Patients who presented with fractures at sites consistent with fragility-type fractures were identified through a retrospective chart review of fracture clinic visits in 3 Ontario community hospitals in selected weeks in February and November 1996 and August and May 1997. These patients were contacted by mail and telephone follow-up to obtain consent to participate in a telephone interview. Patients were excluded if the index fracture had been traumatic, if they were younger than 18 years, or if they had medical conditions known to be associated with secondary bone loss. Eligible patients were questioned about their history of prior fractures, diagnosis of osteoporosis, and investigation and treatment of osteoporosis before or after the index fracture. RESULTS: Among 2694 fracture clinic visits, we identified 228 patients (8.4%) with fragility-type fractures. Of the 228, 128 (56.1%) were contacted and agreed to participate in an interview about 1 year from the date of the index fracture. Of the 128 patients, 108 (83 postmenopausal and 13 premenopausal women and 12 men) were confirmed as eligible. Of the 108, 43 had experienced 53 fractures in addition to the index fracture in the preceding 10 years, of which 71% were of the fragility type. At interview, only 20 (18.5%) (all postmenopausal women) of the 108 patients reported that they had received a diagnosis of osteoporosis. Of the 20, 90% and 45% respectively had been advised to take calcium and vitamin D supplements; 8 (40%) were receiving hormone replacement therapy (HRT), and 8 (40%) were taking bisphosphonates. Of the 88 patients who had not received a diagnosis of osteoporosis, 4 (4.5%) were receiving HRT, none was taking bisphosphonates, and less than 20% had been advised to take supplemental calcium or vitamin D. INTERPRETATION: In a representative sample of patients at urban fracture clinics, less than 20% who presented with a fragility-type fracture had undergone investigation and adequate treatment of osteoporosis at 1-year follow-up. Since previous fracture significantly increases the risk for future fracture, this clearly is a deficiency in management. Through improved identification and treatment of patients with osteoporosis-related fractures who present to fracture clinics, there is a significant opportunity to reduce the rates of illness and death associated with this condition.

Acute metastatic infection of a revision total hip arthroplasty with oral bacteria after noninvasive dental treatment.

The risk of hematogenous bacterial infection of a total joint prosthesis is currently considered to be greatest in the 2 years after arthroplasty or when the patient is chronically ill or immunocompromised, for dental treatments that are considered invasive, with a higher incidence of bacteremia. We report the case of a healthy man who had undergone revision hip arthroplasty 11 months previously and who developed acute signs of infection of the hip prosthesis with an oral organism 30 hours after supragingival dental cleaning, performed with the specific intention to be noninvasive, without antibiotic prophylaxis.