Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

BACKGROUND: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. METHODS: In January-March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. RESULTS: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). CONCLUSION: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. LEVEL OF EVIDENCE: IV.

The Estimated Cost of Maintenance of Certification.

BACKGROUND: Maintenance of Certification (MOC) is a controversial topic in medicine for many different reasons. Studies have suggested that there may be associations between fewer negative outcomes and participation in MOC. However, MOC still remains controversial because of its cost. We sought to determine the estimated cost of MOC to the average orthopaedic surgeon, including fees and time cost, defined as the market value of the physician's time. METHODS: We calculated the total cost of MOC to be the sum of the fees required for applications, examinations, and other miscellaneous fees as well as the time cost to the physician and staff. Costs were calculated for the oral, written, and American Board of Orthopaedic Surgery Web-based Longitudinal Assessment (ABOS WLA) MOC pathways based on the responses of 33 orthopaedic surgeons to a survey sent to a state orthopaedic society. RESULTS: We calculated the average orthopaedic surgeon's total cost in time and fees over the decade-long period to be $71,440.61 ($7,144.06 per year) for the oral examination MOC pathway and $80,391.55 ($8,039.16 per year) for the written examination pathway. We calculated the cost of the American Board of Orthopaedic Surgery web-based examination pathway to be $69,721.04 ($6,972.10 per year). CONCLUSIONS: The actual cost of MOC is much higher than just the fees paid to organizations providing services. The majority of the cost comes in the form of time cost to the physician. The ABOS WLA was implemented to alleviate the anxiety of a high-stakes examination and to encourage efficient longitudinal learning. We found that the ABOS WLA pathway does save time and money when compared with the written examination pathway when review courses and study periods are taken. We believe that future policy changes should focus on decreasing physician time spent completing MOC requirements, and decreasing the cost of these requirements, while preserving the model of continued evidence-based medical education.

Assessing the performance and learning curve of orthopaedic surgical trainees in primary total hip arthroplasty.

INTRODUCTION: The aims of this study were threefold: first, to review the surgical performance of trainees in our departments by reviewing postoperative radiographs and operative times; second, to investigate the effect of supervision and assistant grade on postoperative radiographs and operative times; and third, to monitor trainees over a 6-month period looking for changes in postoperative radiograph appearances and operative times to assess whether these parameters reflect a trainee's learning curve. METHODS: A retrospective evaluation of a continuous series of primary hip arthroplasty procedures performed by 12 trainee orthopaedic surgeons (StR) during their arthroplasty rotation. In total, 348 primary total hip replacement (pTHR) operations were performed by StRs. Operative time, acetabular cup inclination, radiological leg length discrepancy (rLLD), femoral stem alignment (FSA) and the Barrack score for cementation were evaluated. The mean number of pTHRs performed per 6-month placement was 29 (range 15-51). Operative times were available for 292 cases and all postoperative imaging was evaluated. RESULTS: The mean operative time for StRs as first-surgeon was 84.3 minutes (range 42-174 minutes). Significant differences in operative times were observed between individual StRs. As a cohort, the operative times were not affected by the level of supervision but were significantly slower when StRs were assisted by other StRs. Significant differences in rLLD, FSA and Barrack score for cementation were observed across the cohort of StRs, although this did not change at a group or individual level between the first and second halves of the 6-month placement. CONCLUSIONS: Used in isolation, postoperative radiographs and operative time are not an effective measure of the learning curve in primary hip arthroplasty, however, they may be a useful adjunct in assessing the performance of orthopaedic trainees when learning primary hip arthroplasty.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

BACKGROUND: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions. QUESTION/PURPOSE: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States? METHODS: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively. RESULTS: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth. CONCLUSION: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains. CLINICAL RELEVANCE: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

Evaluación de los resultados en el tratamiento de los pacientes con fracturas de pilón tibial / Outcomes assessment in the treatment of patients with tibial pylon fractures

RESUMEN Introducción: las fracturas de pilón tibial son un desafío para el cirujano y actualmente existe controversia en cuanto a su tratamiento. Objetivo: evaluar los resultados del tratamiento aplicado. Materiales y métodos: se realizó un estudio observacional, descriptivo, longitudinal, con el universo de estudio de todos los pacientes que fueron atendidos y tratados con fractura de pilón tibial desde el 1 de enero de 2015 al 31 de diciembre de 2016. Se seleccionó una muestra de 27 pacientes. Resultados: hubo un predominio del sexo masculino (78 %), y del grupo de edades de 40 a 49 años para ambos sexos (37 %). Prevalecieron las fracturas producidas por accidentes de tránsito, con 59 %. Las fracturas cerradas fueron las más representadas, con 78 %. El 67 % de los pacientes no presentaron lesiones asociadas y predominaron las fracturas tipo II en el 55 % del total. Se aplicó tratamiento quirúrgico a un 74 % y se logró la consolidación en un 78 % de los casos antes de las 16 semanas. Antes de las 20 semanas se le indicó el apoyo al 78 % de los casos. Se complicaron 13 pacientes, para un 48 % del total. A pesar de ello, como resultado final, fueron evaluados de excelente y bien el 63 % de los pacientes. Conclusiones: la fractura de pilón tibial constituye una lesión de muy difícil manejo para el cirujano traumatólogo de hoy (AU).

ABSTRACT Introduction: tibial pylon fractures are a challenge for the surgeon surgery and currently there is a controversy regarding their treatment. Objective: to assess the outcomes of the applied treatment. Materials and methods: an observational, descriptive, longitudinal study was carried out with the study universe of all the patients who were attended and treated with tibial pylon fracture from January 1st, 2015 to December 31st, 2016. A sample composed by 27 patients was chosen. Results: male sex (78 %) and both-sexes 40-49 age group (37 %) predominated. There was a predominance of fractures caused by traffic accidents with 59 %, being closed fractures the most represented ones, with 78 %. 67 % of the patients did not present associated injuries, being type II fractures predominant in 55 % of the total. 74 % of the cases underwent surgery, achieving consolidation in 78 % of the cases before 16 weeks. Before 20 weeks, 78 % of the cases were indicated to set on their foot, and 13 patients had complications, representing 48 % of the total. In spite of this, 63 % of the patients were evaluated as excellent and well as final outcome. Conclusions: the tibial pylon fracture is an injury of very difficult handling for the today's orthopedic surgeon (AU).

Challenges for Joint Commission International accreditation: performance of orthopedic surgeons based on International Patient Safety Goals.

The Joint Commission International (JCI) is a US-based organization that accredits and certifies hospitals worldwide. Among the requirements for accreditation, the JCI emphasizes continuous quality improvement (CQI) with regard to international patient safety goals (IPSGs). Our university hospital treats about 26,000 hospitalized patients and 600,000 outpatients annually, and our goal is patient safety in compliance with IPSGs. The purpose of this study is to examine the activities of orthopedic surgeons in preparation for JCI accreditation, including clear identification of patients, preoperative timeout and marking to ensure correct surgery, timely approval of CT/MRI reports, care with pain management, prevention of infection, setting of quality indicators and daily monitoring, and teamwork. Examiners from the JCI visited our hospital to review medical records and documents, and to interview patients, nurses and doctors. There were 1270 evaluation items covering 16 fields, including reviews of IPSGs, patient evaluation and care, infection prevention and control, and governance and leadership. Most importantly, the efforts of all the medical staff in our hospital in obtaining the first JCI accreditation among national university hospitals in Japan have promoted the safety and quality of medical care from the perspective of the patient.

Use of traction table did not increase complications in total hip arthroplasty through direct anterior approach performed by novice surgeon.

PURPOSE: The purpose of this study was to investigate the surgical outcomes of total hip arthroplasty (THA) through direct anterior approach (DAA) performed by beginners by comparing the outcomes after the introduction of DAA-THA between using a normal operating table and a traction table. METHODS: The total subjects were 200 patients, there were 120 cases from the introduction of three surgeons using a normal table and 80 cases from two surgeons using a traction table. The surgical procedure was standardized, and a surgeon skilled in DAA entered the operating room and instructed the novice surgeons of DAA in all cases. RESULTS: The mean operative time was no significant difference between the two groups (p = 0.093). The difference in slope of the operative time was no significant difference between the two groups (p value = 0.089). The mean fluoroscopy time and the mean blood loss were significant difference between the two groups (p < 0.05). The difference in slope of the fluoroscopy time and blood loss were significant difference between the two groups (p < 0.05). There were no intraoperative complications and no reoperations for any reason. CONCLUSIONS: At the facility with a surgeon skilled in DAA, the use of a traction table in DAA did not increase the complication rate compared with the use of a normal operating table when the exclusion criteria for DAA were set and surgery was performed using intraoperative fluoroscopy under supervision by a skilled surgeon.

The Influence of Physician-Rating Websites on Patient Physician Preference.

BACKGROUD: Physician-rating websites (PRWs) are designed to publicly report physician quality information while bringing forth a sense of transparency. This study looks to identify the influence PRWs have on a patient's choice of orthopedic hand surgeon while stratifying patient physician preference by various demographic characteristics. METHODS: This survey-based study was conducted in a suburban outpatient orthopedic hand practice. All patients between 18 to 89 years of age who presented for an appointment were asked to participate. Survey questions aimed to identify patient demographics and the sources patients used to choose their hand surgeon. RESULTS: Overall, 104 patients completed our survey. Our study population was predominantly between 51 and 70 years of age (50.0%), women (60.6%), and Caucasian (84.6%), received a general education degree or high school diploma (36.5%), was employed (49.0%), and owned private health insurance (59.6%). One hundred and two patients (98.1%) answered that their physician's reputation is important. Seventy-five patients (72.1%) reported that they heard about their surgeon by physician referral, while only two (1.9%) used online search engines. Sixty-six patients (63.5%) noted that physician referrals were most trustworthy. Only 10 patients (9.6%) consulted PRWs to choose their surgeon, most of whom were younger than 50 years (n = 6), Caucasian (n = 8), and employed (n = 7) and had schooling after high school (n = 8). CONCLUSIONS: Despite increases in digital information exchange platforms, PRWs are not commonly used by suburban orthopedic hand patients to exchange information about or choose their hand surgeon. Patients still primarily rely on physician referrals and word of mouth from family and friends to choose their surgeon.

Evaluation of Spanish Language Proficiency and Resources Available in Academic Pediatric Orthopaedic Centers.

INTRODUCTION: Given the rapidly increasing population of Spanish-speaking patients in the United States, medical providers must have the capability to effectively communicate both with pediatric patients and their caregivers. The purpose of this study was to query the Spanish language proficiency of pediatric orthopaedic surgeons, assess the educational resources available to Spanish-speaking patients and their families, and identify the barriers to care at academic pediatric orthopaedic centers. METHODS: The Web sites of medical centers within the United States that have pediatric orthopaedic surgery fellowships recognized by the Pediatric Orthopaedic Society of North America (POSNA) were accessed. Web sites were investigated for a health library as well as the availability of interpreter services. Profiles of attending surgeons within each Pediatric Orthopaedic Department were evaluated for evidence of Spanish proficiency as well as educational qualifications. Centers were contacted by phone to determine if the resources and physicians who could converse in Spanish were different than what was readily available online and if automated instructions in Spanish or a person who could converse in Spanish were available. RESULTS: Forty-six centers with 44 fellowship programs were identified. The profiles of 12 of 334 (3.6%) surgeons who completed pediatric orthopaedic fellowships indicated Spanish proficiency. Seventeen physicians (5.1%) were identified as proficient in Spanish after phone calls. Thirty-eight pediatric orthopaedic centers (82.6%) noted interpreter service availability online, although services varied from around-the-clock availability of live interpreters to interpreter phones. When contacted by phone, 45 of 46 centers (97.8%) confirmed the availability of any interpreter service for both inpatient and outpatient settings. Sixteen centers (34.8%) had online information on orthopaedic conditions or surgical care translated into Spanish. Twenty centers (43.5%) did not have automated phone messages in Spanish or live operators that spoke Spanish. CONCLUSIONS: There is a scarcity of surgical providers in pediatric orthopaedic centers proficient in Spanish, demonstrating a large discrepancy with the growing Hispanic population. Interpreter services are widely available, although there is variability in the services provided. Considerable barriers exist to Spanish-speaking patients who attempt to access care by phone or online.

Coronal Remodeling Potential of Pediatric Distal Radius Fractures.

BACKGROUND: Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of coronal remodeling, via the distal radius physis, present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures. METHODS: A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture with over 10 degrees of angulation in the coronal plane during the healing process at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2009 to 2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling. RESULTS: In total, 36 patients with distal radius fractures with a mean age of 7.93 years (range, 4 to 12 y) at the time of injury were identified. The median peak angulation during the healing process in the coronal plane was 17 degrees (range, 12.4 to 30.4 degrees). The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 6.59 months (range, 2.5 to 8.72 mo). At final follow-up, the median coronal angulation was 3.35 degrees (range, 0.24 to 14.0 degrees). At the 95% confidence level, remodeling rates ranged from 2.00 to 2.59 degrees per month. The mean rate of coronal angulation remodeling from maximum angulation to final follow-up was 2.30 degrees per month. CONCLUSIONS: Distal radius fractures have a large capacity to remodel in the pediatric population. This remodeling occurs in a predictable and reliable manner, even in the coronal plane. On the basis of this study, coronal angulation was shown to remodel at a rate of at least 2 degrees per month for the first 6 months following the injury, which should likely continue at a similar rate for the first year after the injury. Repeat manipulation is not indicated in skeletally immature patients where the maximum coronal angulation is <24 degrees, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year after fracture. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Survey on the surgical skills of orthopedics and traumatology residents from accredited and nonaccredited institutions in Istanbul.

OBJECTIVE: To investigate whether orthopedic and traumatology residents who are undergoing training achieve competence in surgical techniques after completion of their specialization and to determine whether there are significant differences between the responses of residents from accredited and nonaccredited institutions. METHODS: A total of 131 orthopedics and traumatology residents from nine institutions in the Istanbul province answered the questionnaire during the morning training meeting. In addition to basic demographic data, level of seniority, equipment competence, and theoretical and practical training, the residents were asked about their opinion on what type of surgeries they could perform after their specialization, considering the surgery and follow-up of the case as well as the complications occurring during this period. The residents responded to questions on 46 surgeries under the main headings of trauma, arthroscopy, arthroplasty, spine, pediatric orthopedics, hand surgery, deformity, and bone and soft tissue tumors. In addition to descriptive statistical methods, one-way analysis of variance, Tukey's multiple comparison test, and chi square test were used to evaluate the data. The significance level for the results was set at p<0.05. RESULTS: In total, 131 orthopedics and traumatology residents answered the questionnaire. Furthermore, 53 (40.5%) specialization students were employed at accredited institutions and 78 (59.5%) at nonaccredited institutions. According to the responses, case presentations, article-writing sessions, and in-province meetings held regularly at accredited institutions showed a significant difference compared to non-accredited institutions (p<0.05), and the residents at the accredited institutions benefited significantly more from the availability of books and electronic media in gaining theoretical knowledge (p<0.05). When the responses of the residents from accredited and nonaccredited institutions regarding 46 different surgeries were compared, a significant difference was found in 17 of them (p<0.05). There was a significant difference between the averages of residents' responses on the surgical fields they have interest for (p<0.05). It was determined that the residents believed that they could mostly perform surgeries in the fields of trauma, followed by arthroplasty, deformity, arthroscopy, pediatric orthopedics, hand surgery, and spine and tumor surgery. According to their level of seniority, a significant difference was found between the averages of residents' opinions regarding their surgical skill levels (p=0.02). CONCLUSION: We believe that it would be beneficial for the trainers to take necessary precautions to increase the skill levels of the residents of orthopedic surgery. Accreditation significantly contributes to the standardization of education as well as quality improvement. Further action should be taken to increase the number of accredited clinics.

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries.

BACKGROUND: Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. METHODS: One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. RESULTS: Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). CONCLUSIONS: Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. LEVEL OF EVIDENCE: III.

Management of hospitalised osteoporotic vertebral fractures.

Management of hospitalised osteoporotic vertebral fracture patients was explored across all major trauma orthopaedic hospitals in Ireland. Findings, based on a survey of orthopaedic doctors and physiotherapists, indicate a lack of standardised clinical care pathways. This study will inform development of clinical audit mechanisms and health service development for this large and growing fracture population in both Ireland and internationally. PURPOSE: To explore the management of hospitalised vertebral fragility fracture (VFF) patients in Ireland. METHODS: A cross-sectional survey of orthopaedic doctors (specialist registrar level) and physiotherapists was conducted across all hospitals with major orthopaedic trauma units in Ireland. Data were analysed using descriptive statistics in SPSS (V24). RESULTS: Responses were achieved from 100% (n = 16) of the hospitals (42 individual physiotherapists and 47 orthopaedic doctors). Conservative management was usual with both orthopaedic doctors (n = 37, 79%) and physiotherapists (n = 40, 96%) reporting prescription of bracing as common practice despite a lack of underpinning evidence. A majority (87%) of the doctors believed osteoporosis medications should commence prior to discharge from the acute setting, but 68% did not agree that responsibility for coordination and delivery of bone health assessment and fracture risk management rested with them. A majority (72%) of physiotherapists reported an absence or were unsure regarding existence of fracture liaison services. 73% of physiotherapists reported prescribing an inpatient or home (78%) exercise programme, including mobility, strength and balance exercise though detail on dose and adherence remain unknown. Wide variance in referral patterns to multi-disciplinary team (MDT) members existed although 79% of orthopaedic doctors supported an MDT approach. CONCLUSION: Clinical care pathways for the hospitalised VFF population lack standardisation in Ireland. Key challenges reported by orthopaedic doctors and physiotherapists relate to pain management, osteoporosis medication prescription, clarity on indications for bracing and a lack of fracture liaison services. Clinical guidelines, defined clinical care pathways and high-quality clinical research trials are required for VFF management.

Online ratings of spinal deformity surgeons: analysis of 634 surgeons.

STUDY DESIGN: Observational study. OBJECTIVE: To evaluate the online ratings of spine deformity surgeons and variables that may affect online ratings Physician review websites (PRW) continue to be an emerging trend in the US across all specialties. Previous literature with smaller sample sizes revealed that most spine surgeons are rated on at least on PRW. To date, the online ratings of spinal deformity surgeons have not been evaluated. MATERIALS AND METHODS: A review of the 2017 Scoliosis Research Society (SRS) Fellowship directory for active fellows and candidate members yielded 634 active members. Online ratings from five PRWs were recorded and scaled from 0 to 100. Using SPSS, one-way analysis of variance was used to compare differences between multiple groups. A t test was used to compare differences between two groups. Significance was set at p < 0.05. RESULTS: Most surgeons (98.7%) were rated on at least one PRW. Surgeons in academic or hospital practice had higher ratings than those in private practice (83.4 vs. 78.8, and 83.7 vs. 78.8, p < 0.001). Surgeons with 0-5-year experience had higher ratings than more experienced surgeons (p < 0.001). However, surgeons in practice for 0-5 years also had fewer reviews than their more experienced colleagues (p < 0.05). We found no differences in ratings based on sex, specialty, or region. The largest differences in ratings between high and poorly rated spine surgeons was in areas pertaining to the doctor-patient relationship (answering questions, time spent with the patient). CONCLUSION: The majority (98.7%) of SRS surgeons are rated on at least one PRW. SRS surgeons in practice between 0 and 5 years have higher ratings than more experienced surgeons, but were rated by fewer patients than their more experienced counterparts. Higher ratings were associated with variables pertaining to the patient-doctor relationship. LEVEL OF EVIDENCE: IV.

Shoulder arthroplasty for glenohumeral osteoarthritis: results from a comprehensive survey in Belgium and the Netherlands.

The purpose of this survey in Belgium and the Netherlands was to assess treatment variation in glenohumeral osteoarthritis between experienced and less experienced orthopedic surgeons, and to investigate perioperative treatment after shoulder arthroplasty in a large group of orthopedic surgeons. Orthopedic surgeons specialized in shoulder surgery were invited to complete a survey between November 2013 and February 2015. Seventy-one percent of the approached surgeons com-pleted the survey. Less experienced surgeons (< 6 years) and surgeons from the Netherlands find patient characteristics (e.g. smoking p=0.01) more relevant than more experienced surgeons (≥ 6 years) and surgeons from Belgium. Less experienced surgeons will less likely (p=0.001) perform resurfacing arthroplasty compare to experienced surgeons. The less and the experienced surgeons use similar indications for a reverse shoulder arthroplasty regarding age limit and cuff arthropathy without osteoarthritis. Less experienced surgeon will more likely (p=0.003) prescribe a low molecular weight heparin during the hospital stay after a shoulder arthroplasty. In this survey, we found a decrease in the use of resurfacing arthroplasty and a strong increase in the use of reverse shoulder arthroplasty. Besides, there is little consensus concerning pre-operative planning, patient characteristics, surgical technique, and patient reported outcome measures. Level of evidence: IV.

Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons.

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

Technical Obstacles for Low-Volume Surgeons in Primary Anterior Cruciate Ligament Reconstruction.

A longer surgical time will lead to postoperative complications in orthopaedic surgery. According to previous reports, surgeon volume affects a surgical time in anterior cruciate ligament (ACL) reconstruction. However, little attention has been paid to difference of a surgical time between high- and low-volume surgeons in ACL reconstruction. The purpose of the present study was to investigate the surgical time for both high- and low-volume surgeons and to clarify technical obstacles as well as the important technique to reduce the surgical time in ACL reconstruction. A total of 103 knees in 103 patients with ACL tear were enrolled. All the procedures were performed by 13 different surgeons. The surgeons were divided into two surgeon groups (high- and low-volume groups) based on the number of annual cases. The operative technique was divided into the same five steps to perform comparisons of step-by-step surgical time between the surgeon groups of different volumes. The statistical comparison was done between high- and low-volume groups in terms of surgical time in each step. Total operation times were 87.8 ± 17.6 and 129.9 ± 42.9 minutes in high- and low-volume group, respectively. Low-volume surgeons took much time in tendon harvesting and bone tunnel creation using arthroscopy. Low-volume surgeons took more time for primary ACL reconstruction, especially in tendon harvesting, compared with high-volume surgeons. Tendon harvesting was extremely important, as well as bone tunnel creation, for low-volume surgeons to reduce surgical time in primary ACL reconstruction.