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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.

Category: Ankle; Ankle Arthritis Introduction/Purpose: There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post- operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty. Methods: This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into quintiles based on equal amounts over the range of incomes. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t- test. Results: A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post- operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. Conclusion: Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients.

Background Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections. Methods We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates. Results Our sample included 35 patients. The mean age at surgery was 15.1 ± years, 65.7% were girls, and mean follow-up was 41.7 ± months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group ( n = 21) were more likely than those in the implant retention group ( n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04). Conclusion Implant retention should be considered, irrespective of the timing or depth of the infection.

The effects of the COVID-19 pandemic on elective orthopedic surgery have yet to be reported at the population level in Canada. We sought to detail the effect of the pandemic on patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA), and on surgeons with respect to surgical volume, wait times and health care quality. We compared patient length of hospital stay, revisions, readmissions and emergency department presentations between pre-pandemic (April 2019 to February 2020) and postpandemic (April 2020 to February 2021) cohorts of patients who underwent inpatient THAs or TKAs. Wait times for THA and TKA in Ontario were similarly collected. Case volumes for THA and TKA decreased by 30% during the pandemic. There were significantly fewer medically complex cases during this time period (p < 0.001). Length of hospital stay was reduced from 2.2 to 1.8 days (p < 0.001). Patients were less likely to visit the emergency department within 30 days of surgery (p < 0.001). Patients who underwent TKA were also more likely to be discharged directly home (p = 0.025). There was no difference in rate of revision surgery or readmission within 30 days. The proportion of patients meeting the standard benchmark wait time in Ontario was significantly lower (p < 0.001). The corresponding wait time to treatment increased significantly (p < 0.001). The effects of the COVID-19 pandemic on elective THA and TKA case volumes and wait times was significant. Patients having surgery during the pandemic were less medically complex, had shorter length of hospital stays and had significantly less health care utilization. Il convient de faire un bilan des répercussions de la pandémie de COVID-19 sur les chirurgies orthopédiques non urgentes à l’échelle de la population canadienne. Nous avons voulu analyser ces répercussions sur les malades soumis à une chirurgie pour prothèse totale de la hanche (PTH) et pour prothèse totale du genou (PTG), et sur les orthopédistes aux plans des volumes de cas, des temps d’attente et de la qualité des soins. Nous avons comparé la durée des séjours hospitaliers, les révisions, les réadmissions et les consultations dans les services d’urgence entre les cohortes hospitalisés pour PTH et PTG en période pré- (d’avril 2019 à février 2020) et postpandémique (d’avril 2020 à février 2021). Les temps d’attente pour les PTH et les PTG en Ontario ont également été consignés. Les volumes de PTH et de PTG ont diminué de 30 % durant la pandémie. On a enregistré un nombre significativement moindre de cas médicalement complexes pendant cette période (p < 0,001). La durée des séjours hospitaliers est passée de 2,2 jours à 1,8 jour (p < 0,001). Les patients étaient moins susceptibles de consulter dans un service d’urgence dans les 30 jours suivant leur chirurgie (p < 0,001). Les cas de PTG étaient aussi plus susceptibles de recevoir leur congé pour retourner directement à la maison (p = 0,025). On n’a noté aucune différence quant aux révisions chirurgicales ou aux réadmissions dans les 30 jours. La proportion de patients pour qui le délai d’attente correspondait aux temps de référence en Ontario a été significativement moindre (p < 0,001). Le temps d’attente correspondant avant le traitement a significativement augmenté (p < 0,001). La pandémie de COVID-19 a eu des répercussions significatives sur les volumes de cas de PTH et de PTG non urgents et sur les temps d’attente. Les cas soumis à la chirurgie durant la pandémie étaient médicalement moins complexes, la durée des séjours a été plus brève et l’utilisation des services de santé a diminué significativement.

Background Wrong-site, wrong-procedure and wrong-patient surgeries are catastrophic events for patients, medical caregivers and institutions. Operating room (OR) briefings are intended to reduce the risk of wrong-site surgeries and promote collaboration among OR personnel. The purpose of our study was to evaluate 2 OR briefing safety initiatives, “07:35 huddles” (preoperative OR briefing) and “surgical time-outs” (perioperative OR briefing), at the Hospital for Sick Children in Toronto, Ont. Methods First, we evaluated the completion and components of the 07:35 huddles and surgical time-outs briefings using direct observations. We then evaluated the attitudes of the OR staff regarding safety in the OR using the “Safety Attitudes Questionnaire, Operating Room version.” Finally, we conducted personal interviews with OR personnel. Results Based on direct observations, 102 of 159 (64.1%) 07:35 huddles and 230 of 232 (99.1%) surgical time-outs briefings were completed. The perception of safety in the OR improved, but only among nurses. Regarding difficulty discussing errors in the OR, the nurses’ mean scores improved from 3.5 (95% confidence interval [CI] 3.2–3.8) prebriefing to 2.8 (95% CI 2.5–3.2) postbriefing on a 5-point Likert scale ( p < 0.05). Personal interviews confirmed that, mainly among the nursing staff, pre- and perioperative briefing tools increase the perception of communication within the OR, such that discussions regarding errors within the OR are more encouraged. Conclusion Structured communication tools, such as 07:35 huddles and surgical time-outs briefings, especially for the nursing personnel, change the notion of individual advocacy to one of teamwork and being proactive about patient safety.

Purpose The aim of this study was to identify the survivorship of high tibial osteotomy (HTO) to total knee arthroplasty (TKA) on a population level, and identify the patient, provider and surgical factors that influenced eventual TKA. Methods Administrative records from physician billings and hospital admissions were used to identify all adults in Ontario, Canada, who underwent an HTO from 1994 to 2010. The primary outcome was time to TKA, which was estimated using Kaplan–Meier (KM) survival analysis. A Cox proportional hazards model examined the risk associated with patient factors (age, sex, income and co-morbidity score), provider factors (hospital status, surgeon volume and surgeon year in practice) and surgical factors (concurrent ligament reconstruction or bone grafting; and previous chondral or meniscal surgery). Results A total of 2671 patients who underwent HTO met inclusion. The median age was 46 years (interquartile range 39–53 years), and 62 % were male. The KM survivorship of HTO to TKA at 10 years was 0.67 ± 0.01. Older age [HR 1.05 (95 % CI 1.04, 1.06), p  < 0.001; 5 % increased risk for each year over age 46], female sex [HR 1.35 (95 % CI 1.17, 1.55), p  < 0.001], higher comorbidity score [HR 1.58 (95 % CI 1.12, 2.22), p  = 0.009] and a prior history of arthroscopy/meniscectomy [HR 1.24 (95 % CI 1.08, 1.43), p  = 0.002] increased the risk of eventual TKA. However, HTO with concurrent ligament reconstruction was associated with lower [HR 0.62 (95 % CI 0.43, 0.88), p  = 0.008] risk of eventual TKA. Conclusion In this population, two-thirds of patients were able to avoid a TKA for 10 years after HTO. Specific factors such as older age, female sex, higher comorbidity and prior meniscectomy lowered survival rates. An understanding of patient risk factors for conversion to TKA may help guide surgeons in their selection of patients who will benefit most from HTO. Level of evidence Retrospective cohort study, III.

Objectives: Most clinical studies pertaining to shoulder dislocation use age cutoffs of 16 years, and at present, only small case series of patients aged 10-16 years guide our management. Using a general population cohort aged 10 to 16 years, we sought to: 1) determine the overall and demographic-specific incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR), and 2) determine the rate of and risk factors for repeat shoulder CR. Methods: Using administrative databases, we identified all patients who underwent CR of a primary anterior shoulder dislocation by a physician in Ontario between April 2002 and September 2010 (the index event). Exclusion criteria included age (16 years), posterior dislocation, and prior shoulder dislocation or surgery. The IDR was calculated for the entire cohort and compared by age and sex subgroups. The main outcome, repeat shoulder CR, was sought until September 2012. A time-to-event analysis (cumulative incidence function) was used to determine the incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years for the entire cohort and subgroups based on age (10-12, 13, 14, 15, and 16 years). A competing risk model identified risk factors for repeat shoulder CR, which were reported using hazard ratios (HR) with 95% confidence intervals (CI). Results: We identified 2,066 patients aged 10-16 years who underwent CR following a primary anterior shoulder dislocation, of which, 1,937 met the exclusion criteria. The median age was 15.0 years and 79.7% were male. The IDR was 20.1 per 100,000 person-years, and was highest among 16 year-old males (164.4 per 100,000 person-years). In contrast, primary anterior shoulder dislocation was rare among patients aged 10-12 years [5.9% (N=115) of all primary dislocations]. Repeat shoulder CR was observed in 740 patients (38.2%) after a median of 0.8 years. The overall cumulative incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years was 13.0%, 21.3%, 29.2%, and 36.2%, respectively; however, the cumulative incidence by age (Figure 1) revealed the rate of repeat shoulder CR to be highest among 14-16 year-olds (37.2-42.3%), and considerably less among patients aged 10-13 years (0-25.0%). Male sex (HR 1.2, p=0.04; interpreted as a 20% increased risk for males as compared to females) and patient age (HR 1.2, p<0.001; interpreted as a 20% increased risk for each year over age 10) significantly influenced the risk of a repeat shoulder CR. Overall, 31.2% (N=604) of patients underwent shoulder stabilization, of which, half underwent surgery following the index shoulder CR (49.9%, N=369). Conclusion: Primary anterior shoulder dislocations are common among 14-16 year olds, and the rate of recurrence in this age group following non-operative management mirrors that of 17-20 year olds in previously published data. In contrast, both the incidence of primary anterior dislocation and rate of recurrence are considerably lower for patients aged 10-13 years. Going forward, clinicians should treat and counsel patients aged 14-16 years, particularly males, as they do older adolescents (17-20 years); however, patients 13 years of age or younger should be counselled regarding their low risk for recurrence.

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.