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There is increasing concern regarding the lack of physicians and underresourcing of the medical system in Canada. The training of orthopedic surgeons has emerged as an area of particular concern. The purpose of this study was to gain insight into the outcomes of graduates of orthopedic surgery residency programs in Ontario in the last 30 years. We invited graduates of orthopedic surgery residency programs in Ontario from 1992 to 2020 to participate in our survey regarding their practice patterns and career choices. Participants were asked whether they believed their residency had prepared them for independent practice and were asked about their practice patterns after graduation, including whether they completed fellowships. A total of 618 graduates met the inclusion criteria. We had a response rate of 40.9% ( = 253). A total of 62.8% of participants reported feeling ready to enter independent practice, which was less than the 80% expected threshold. This proportion varied by program and, overall, those who had graduated more recently reported feeling less ready. Nearly all participants had completed at least 1 fellowship, with most trainees having completed 2 fellowships. Earlier graduates were less likely to complete 2 or more fellowships. Completing a fellowship did not help with comfort in practice nor with earlier employment. Most respondents reported that their current surgical skills were primarily influenced by fellowship training, regardless of comfort level in entering practice directly out of residency. A substantial proportion of orthopedic graduates reported not feeling comfortable entering practice directly out of residency, with only 62.8% of participants reporting feeling ready for independent practice after graduation. Furtermore, graduates are incurring a significant opportunity cost completing 1 or often 2 fellowships. These findings necessitate an appraisal of our goals in residency education.

To assess whether there is a measurable impairment of median nerve conduction study parameters with uncomplicated distal radius fracture. Patients were assessed prospectively at the time of cast removal (visit 1) after a standard 6-8 week immobilization for uncomplicated distal radius fracture. Patients with prior entrapment neuropathy or polyneuropathy were excluded. Patients were asked to report sensory symptoms. Median and ulnar motor and sensory conduction studies were performed bilaterally, as well as transcarpal stimulation. All electrophysiologic studies were repeated at a follow-up visit 2, on average 7.8 weeks later. 39 patients were assessed at visit 1 and 30 (77%) were available for follow-up visit 2. Paresthesia in the median territory on the fractured side were reported in 20% at visit 1 and 26% at visit 2. Electrophysiological evidence of only mild carpal tunnel syndrome was found on the fractured side in 4/39 at visit 1 and 6/30 at visit 2. There were only 2 cases of moderate-marked median neuropathy, both asymptomatic and on the unfractured side. Median motor and sensory latencies and amplitudes did not show statistically significant differences between fractured and unfractured sides with the single exception of median distal motor latency at visit 1. Median territory paresthesia at the time of cast removal following distal radius fracture are often not associated with electrophysiologic evidence of median neuropathy. Most median nerve electrophysiologic parameters do not significantly differ between the fractured and uninjured sides. Significant traumatic median neuropathy is not likely to be a frequent manifestation of uncomplicated distal radius fracture. Diagnostic analysis, Level III.

[This corrects the article DOI: 10.1371/journal.pone.0231502.].[This corrects the article DOI: 10.1371/journal.pone.0231502.].

A randomized trial evaluating spinal as compared with general anesthesia for hip-fracture surgery in adults 50 years of age or older did not show superiority of spinal anesthesia with respect to a composite of death or an inability to walk unassisted at 60 days. Postoperative delirium occurred in similar percentages of patients in the two groups.

Current national guidelines on caring for hip fractures recommend early mobilization. However, this recommendation does not account for time spent immobilized waiting for surgery. We sought to determine timing of mobilization following hip fracture, beginning at hospital admission, and evaluate its association with medical complications and length of hospital stay (LOS). We performed a retrospective review of prospectively collected data for 470 consecutive patients who underwent surgery for a hip fracture between September 2019 and August 2020 at an academic, tertiary-referral hospital. Outcomes of interest included time from hospital admission to mobilization, complication rate and LOS. We used a binary regression analysis to determine the effect of different surgical and patient factors on the risk of a postoperative medical complication. The mean time from admission to mobilization was 2.8±2.3 days (range 3 h–14 d). There were 125 (26.6%) patients who experienced at least 1 complication. The odds of developing a complication began to increase steadily once a patient waited more than 3 days from admission to mobilization (odds ratio 2.15, 95% confidence interval 1.42–3.25). Multivariate regression analysis showed that prefracture frailty (β = 0.276, p = 0.05), and timing from hospital admission to mobilization (β = 0.156, p < 0.001) and from surgery to mobilization (β = 1.195, p < 0.001) were associated with complications. The mean LOS was 12.2±10.7 days (range 1–90 d). Prolonged wait to mobilization was associated with longer LOS (p = 0.01). Comprehensive guidelines on timing of mobilization following hip fracture should account for cumulative time spent immobilized. Les lignes directrices nationales actuelles en matière de prise en charge des fractures de la hanche recommandent une mobilisation précoce. Cependant, le temps d’immobilisation en attente de la chirurgie n’est pas pris en compte. Nous avons cherché à déterminer le temps écoulé de l’hospitalisation à la mobilisation après une fracture de la hanche et à évaluer les effets de ce délai sur les complications médicales et la durée de séjour à l’hôpital. Nous avons réalisé une revue rétrospective de données recueillies prospectivement auprès de 470 patients consécutifs ayant subi une chirurgie pour fracture de la hanche entre septembre 2019 et août 2020 dans un centre hospitalier universitaire de soins tertiaires. Les paramètres d’intérêt comprenaient le temps écoulé entre l’hospitalisation et la mobilisation, le taux de complications et la durée de séjour. Nous avons utilisé une analyse par régression binaire pour évaluer l’effet de différents facteurs liés à l’intervention et au patient sur le risque de complication postopératoire. Le temps moyen entre l’hospitalisation et la mobilisation s’élevait à 2,8 ± 2,3 jours (3 h–14 j). Parmi les patients, 125 (26,6 %) ont rencontré au moins 1 complication. Le risque d’apparition d’une complication augmentait progressivement à partir de 3 jours d’attente entre l’hospitalisation et la mobilisation (rapport de cotes 2,15, intervalle de confiance à 95 % 1,42–3,25). L’analyse de régression multivariable a montré qu’une fragilité préexistante (β = 0,276, p = 0,05) et le temps écoulé entre l’hospitalisation et la mobilisation (β = 0,156, p < 0,001) et entre l’intervention et la mobilisation (β = 1,195, p < 0,001) étaient liés à des complications. La durée de séjour moyenne s’élevait à 12,2 ± 10,7 jours (1–90 j). Une attente prolongée avant la mobilisation était associée à une plus longue durée de séjour (p = 0,01). Des lignes directrices exhaustives sur le moment de mobilisation après une fracture de la hanche devraient tenir compte du temps d’immobilisation cumulatif.

Despite increased advocacy for patient safety and several large-scale programs designed to reduce preventable harm, most notably surgical checklists, recent data evaluating entire health systems suggests that we are no further ahead in improving patient safety and that hospital complications are no less frequent now than in the 1990s. We suggest that the failure to systematically measure patient safety is the reason for our limited progress. In addition to defining patient safety outcomes and describing their financial and clinical impact, we argue why the failure to implement patient safety measurement systems has compromised the ability to move the agenda forward. We also present an overview of how patient safety can be assessed and the strengths and weaknesses of each method and comment on some of the consequences created by the absence of a systematic measurement system.

Guidelines for urinary catheterization in patients with hip fracture recommend limiting catheter use and using intermittent catheterization preferentially to avoid complications such as urinary tract infection (UTI) and postoperative urinary retention (POUR). We aimed to compare current practices to clinical guidelines, describe the incidence of POUR and UTI, and determine factors that increase the risk of these complications. We retrospectively reviewed the charts of patients with hip fracture who presented to a single large tertiary care centre in southeastern Ontario between November 2015 and October 2017. Data collected included comorbidities, catheter use and length of stay. We compared catheter use to guidelines, and investigated the incidence of and risk factors for POUR and UTI. We reviewed the charts of 583 patients, of whom 450 (77.2%) were treated with a catheter, primarily indwelling (416 [92.4%]). Postoperative urinary retention developed in 98 patients (16.8%); however, it did not affect length of stay (p = 0.2). Patients with indwelling catheters for more than 24 hours after surgery had a higher incidence of POUR than those who had their catheter removed before 24 hours (65/330 [19.7%] v. 10/98 [10.2%]) (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.06–4.38). A UTI developed postoperatively in 62 patients (10.6%). Catheter use was associated with a 6.6-fold increased risk of UTI (OR 6.6, 95% CI 2.03–21.4). Patients with indwelling catheters did not have a significantly higher incidence of UTI than those with intermittent catheterization (57/416 [13.7%] v. 2/34 [5.9%]) (p = 0.2). Patients who developed a UTI had significantly longer catheter use than patients who did not (p < 0.002). Indwelling catheters were used frequently, which suggests low compliance with clinical guidelines. Longer duration of catheter use led to higher rates of UTI and POUR. Further investigation of the reasons for the common use of indwelling rather than intermittent catheterization is needed. Les lignes directrices pour le cathétérisme vésical chez les patients ayant subi une fracture de la hanche préconisent de limiter la pose de sondes à demeure et d’opter plutôt pour le cathétérisme intermittent afin d’éviter les complications telles que l’infection urinaire (ou cystite) et la rétention urinaire postopératoire (RUPO). Nous avons voulu comparer les pratiques actuelles et les lignes directrices cliniques, établir l’incidence des cas de RUPO et d’infection urinaire et déterminer quels facteurs exacerbent le risque à l’égard de ces complications. Nous avons procédé à une analyse rétrospective des dossiers de patients victimes d’une fracture de la hanche ayant consulté dans un grand centre hospitalier universitaire du Sud-Est de l’Ontario entre novembre 2015 et octobre 2017. Les données recueillies incluaient les comorbidités, l’utilisation de cathéters et la durée du séjour. Nous avons comparé le recours au cathéter par rapport aux lignes directrices et évalué l’incidence des cas de RUPO et d’infection urinaire, et les facteurs de risque. Nous avons analysé les dossiers de 583 patients, dont 450 (77,2 %) se sont fait poser un cathéter, principalement à demeure (416 [92,4 %]). La rétention urinaire postopératoire a affecté 98 patients (16,8 %); par contre, cela n’a pas influé sur la durée du séjour (p = 0,2). Les patients qui ont gardé leur sonde à demeure pendant plus de 24 heures après leur chirurgie ont présenté une incidence plus élevée de RUPO que ceux dont la sonde a été retirée en moins de 24 heures (65/330 [19,7 %] c. 10/98 [10,2 %]) (rapport des cotes [RC] 2,2, intervalle de confiance [IC] de 95 % 1.06–4.38). L’infection urinaire postopératoire a affecté 62 patients (10,6 %). Le recours au cathéter a été associé à une augmentation par un facteur de 6,6 du risque d’infection urinaire (RC 6,6, IC de 95 % 2.03–21.4). Les patients à qui on avait posé une sonde à demeure n’ont pas présenté une incidence significativement plus élevée d’infection urinaire comparativement aux patients soumis à un cathétérisme intermittent (57/416 [13,7 %] c. 2/34 [5,9 %]) (p = 0,2). Les patients qui ont présenté une infection urinaire ont gardé leur sonde significativement plus longtemps que les autres patients (p < 0,002). Les sondes à demeure ont été utilisées souvent, ce qui n’est pas conforme aux lignes directrices cliniques. Une sonde portée plus longtemps a entraîné une hausse des taux d’infection urinaire et de RUPO. Il faudra explorer les raisons de l’utilisation répandue des cathéters à demeure plutôt qu’intermittents.

This study investigated castile soap versus normal saline irrigation delivered by means of high, low, or very low pressure for open fractures. Reoperation rates were similar, regardless of irrigation pressure; the rate was higher in the soap group than in the saline group. The initial management of open fractures requires thorough irrigation and débridement 1 – 4 to prevent infection and promote wound and bone healing. 2 , 4 Clinicians accomplish débridement by removing all visible debris and necrotic tissue and by providing copious irrigation of the wound. Controversy exists regarding the choice of irrigation pressure and solution. 4 – 13 High pressure may be more effective than low pressure in removing particulate matter and bacteria 7 – 10 but at the expense of bone damage 8 , 11 and a resultant delay in bone healing. 12 Low pressure may avoid bone damage and delayed healing but at the possible cost of less effective . . .

PurposeIn 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated.MethodsWe conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure.ResultsWe identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (−2.5%; 95% CI, −3.7 to −1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home.ConclusionEvaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care.Study registrationOpen Science Framework (https://osf.io/2938h/); first posted 13 June 2022.