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Research Type: Level 4 – Case series Introduction/Purpose: The Forgotten Joint Score (FJS-12) measures hip and knee patients’ ability to forget their replaced joint in everyday life. This study evaluates whether the FJS-12 includes the appropriate items for total ankle replacement (TAR) patients to ensure findings are accurate and meaningful. Methods: An internet-based, cross-sectional survey of TAR patients and clinicians with TAR experience examined the relevance, comprehensiveness, and comprehensibility of the FJS-12, consistent with COSMIN methodology for content validity. Respondents rated the relevance of FJS-12 items and provided input using open-ended questions on additional necessary content. Cognitive interviews were conducted with 8 patients to evaluate its comprehensibility. Items were considered relevant if ≥70% patients endorsed them. Analysis involved descriptive statistics and content analysis. Results: Sixty-one respondents (54 patients, 12 clinicians) participated. The mean age of the patient sample was 65.3 years, 66.7% were male, 61.1% were retired, and average follow-up length was 2.2 years. Of the 12 FJS-12 items, 3 items were endorsed as relevant, 5 fell just below the threshold, and 4 items were endorsed by < 50% patients. Clinicians endorsed 11 items, with 1 endorsed by only 50.0% of clinicians. Clinicians and patients recommended new content, and patients provided insight into poorly performing items. Conclusion: The FJS-12 lacks content validity for TAR patients. Some items lack sufficient relevance according to patients, and content is missing to allow comprehensive measurement of TAR patients’ ability to forget their joint replacement in daily life. A new FJS-12 will be developed based on this work and undergo psychometric testing in a TAR population.

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

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

Isolated lower limb hypoplasia is a rare consequence of maternal congenital varicella syndrome (CVS). The hypoplastic limb is susceptible to multiple injuries, including fractures, especially if there is associated muscle weakness and lack of sensation. We describe a unique index case of a woman aged 26 years with a background of CVS who presented with a distal femur fracture following a fall onto her insensate, hypoplastic right leg. This report highlights the complexities involved in the diagnosis and management of fractures in patients with an anaesthetic limb, and in particular describes limb amputation as a successful treatment modality for distal femur fractures.

Background and ObjectivesDexmedetomidine has been thought to be an effective adjuvant to local anesthetics in brachial plexus blockade. We sought to clarify the uncertainty that still exists as to its true efficacy.MethodsA meta-analysis of randomized controlled trials was conducted to assess the ability of dexmedetomidine to prolong the duration and hasten the onset of motor and sensory blockade when used as an adjuvant to local anesthesia for brachial plexus blockade versus using local anesthesia alone (control). A search strategy was created to identify eligible articles in MEDLINE, EMBASE, and The Cochrane Library. The methodological quality for each included study was evaluated using the Cochrane Tool for Risk of Bias.ResultsEighteen randomized controlled trials were included in this meta-analysis (n = 1092 patients). The addition of dexmedetomidine significantly reduced sensory block time onset time by 3.19 minutes (95% confidence interval [CI], −4.60 to −1.78 minutes; I2 = 95%; P < 0.00001), prolonged sensory block duration by 261.41 minutes (95% CI, 145.20–377.61 minutes; I2 = 100%; P < 0.0001), reduced the onset of motor blockade by 2.92 minutes (95% CI, −4.37 to −1.46 minutes; I2 = 96%, P < 0.0001), and prolonged motor block duration by 200.90 minutes (CI, 99.24–302.56 minutes; I2 = 99%; P = 0.0001) as compared with control. Dexmedetomidine also significantly prolonged the duration of analgesia by 289.31 minutes (95% CI, 185.97–392.64 minutes; I2 = 99%; P < 0.00001). Significantly more patients experienced intraoperative bradycardia with dexmedetomidine (risk difference [RD], 0.06; 95% CI, 0.00–0.11; I2 = 72%; P = 0.03); however, there was no difference in the incidence of intraoperative hypotension (RD, 0.01; 95% CI, −0.02 to 0.04; I2 = 3%; P = 0.45). It is important to note that all studies reported that intraoperative bradycardia was either transient in nature or reversible, when needed, with the administration of intravenous atropine.ConclusionsDexmedetomidine has the ability to hasten the onset and prolong the duration of blockade when used as an adjuvant to local anesthesia for brachial plexus blockade. Considering an analgesic effect to be either decreased pain, a longer duration of analgesic block, or decreased opioid consumption, the addition of dexmedetomidine to local anesthetics for brachial plexus blockade was found to significantly improve analgesia in all 18 included studies. However, patients receiving dexmedetomidine should be continuously monitored for the potentially harmful but reversible adverse effect of intraoperative bradycardia.Level of EvidenceTherapeutic, level I.

The patient had a total knee replacement for arthritis secondary to Stills disease performed 35 years earlier, with 20 years of good function followed by 15 years of progressively worsening knee pain. A revision was completed, which improved the patient's quality of life and objective knee scores, with an increase in Oxford Knee Score from 22 to 42 and American Knee Society Score from 76 to 170. We discuss the technical aspects in revising this knee replacement, which is the oldest that we are aware of. The result has been a good recovery, which is the first available in the literature for future comparison.

The two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures are plate fixation or intramedullary nailing; however, despite recent evidence, the optimal method to treat such fractures remains a continued topic of debate. A meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate long term function, complications, and operative duration in adult patients receiving intramedullary nailing in comparison to plating. Seven RCTs and three quasi-randomized trials were included. No significant difference was found in long-term function between the two groups (MD: −0.66, 95% CI: −2.03 to 0.71, I 2  = 62%, p = 0.34). Patients who received plating had a 2.19 times increased risk of treatment failure, but this failed to reach significance (95% CI: 0.93 to 5.15, I 2  = 0%, p = 0.07). The risk of non-operative complications was 2.11 times higher in patients who received plating and this reached statistical significance (95% CI: 1.38 to 3.23, I 2  = 53%, p = 0.0006). Finally, plating significantly prolonged operative duration by 20.16 minutes (95% CI: 16.87 to 23.44, I 2  = 56%, p < 0.00001). Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and non-operative complications.

Purpose Operative approach in total hip arthroplasty (THA) has long been a topic of debate with each approach having unique benefits and disadvantages. One purported benefit of an anterior approach to THA is that it allows for intraoperative positioning using fluoroscopy rather than manual positioning. Proper positioning allows for improved outcomes including leg length discrepancy and acetabular component angle. This study aims to examine if operative approach and use of imaging in intraoperative positioning impact LLD and cup angle post-operatively. Methods A total of 300 hips were enrolled in the study with 100 hips per approach (anterior with fluoroscopy, lateral, and posterior). Retrospective chart review was conducted to assess patient demographics and radiographic analysis used to determine LLD and acetabular cup angle. Results Of the three groups, those receiving anterior approach THAs were on average older than those in the posterior group. Analysis comparing the LLD and acetabular angle across the three groups showed no statistically significant difference in LLD ( p =0.091); this was also reflected when comparing hips that received fluoroscopy with those that did not ( p =0.91). For acetabular angle, while no difference existed when comparing hips that received imaging versus those that did not, statistically significant differences were observed when comparing the three intraoperative approaches ( p <0.0001). Conclusions Neither intraoperative approach nor the use of intraoperative imaging in THA has a statistically significant effect on LLD post-operatively. However, approach did impact the acetabular cup angle across all three distinct approaches.

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.

Purpose This study aimed to systematically review the literature to identify the incidence of avascular necrosis (AVN) following hip intra-articular corticosteroid injections (IACSIs) as well as to elucidate risk factors that may predispose patients to AVN following IACSI. Methods The MEDLINE, Embase, PubMed, and Web of Science databases were systematically searched through inception to July 21, 2024, in accordance with the PRISMA statement with data extracted for descriptive analysis. The inclusion criteria were hip IACSI and AVN of the femoral head. AVN identified solely prior to IACSI, animal studies, in vitro studies, and studies on paediatric populations were excluded. Results A total of 3,652 studies were identified and screened resulting in a total of 14 studies that met the inclusion criteria. Seven were case reports, four were retrospective case-series, and three were retrospective cohort studies. The incidence of femoral head AVN following IACSI ranged from 0.6 to 20.4%. Kelly et al. reported that patient-related factors associated with increased rate of AVN included elevated BMI ( p  = 0.025), history of cancer therapy ( p  = 0.012), low serum Vitamin D ( p  = 0.030), and multiple injections ( p  = 0.004). Conclusion In the present literature, the incidence of AVN after hip IACSI ranges from 0.6 to 20.4% with mean follow-up times ranging from 5.4 to 25.3 months. Further randomized controlled trials are necessary to elucidate if there is a causative relationship between hip IACSI and AVN.