Purpose: To investigate

if adding the prospect of co-authorship to a survey’s final paper would increase, and

Method: We identified orthopaedic surgeons through the internet-based Orthopaedic Trauma Association member list. All surgeons received the same questionnaire. In a factorial randomized, controlled fashion, they were allocated

to receive or not receive an additional cover page promising co-authorship of the survey’s final paper if they filled in and returned the survey (an “academic incentive”), and

Results: For 429 surveyed surgeons, six-week response rates were similar for surgeons in the incentive – and no-incentive groups (36.8% vs. 35.4%, respectively, p=0.39). Similarly, response rates did not significantly differ between emailed and faxed surgeons (32.9% vs. 39.9%, respectively, p=0.13). The mean time to response seemed shorter in the incentive-group than in the no-incentive group (p=0.058).

Conclusion: We cannot recommend promising co-authorship to increase the response rates of surveys to orthopaedic surgeons. Additionally, emailed and faxed surveys yielded statistically similar response rates, leaving the decision regarding what modality to employ to time and money constraints.

Purpose: In recent years, there has been an increased appreciation of the importance of intimate partner violence (IPV), which is also known as domestic violence, spouse abuse, and battering, as a serious public health problem. Domestic violence is the most common cause of nonfatal injury to women in North America. As providers of musculoskeletal care and first-contact health care practitioners for many patients, orthopaedic surgeons should be knowledgeable regarding screening and possible interventions for IPV victims. The Canadian Orthopaedic Association and the American Academy of Orthopaedic Surgeons have both prepared explicit statements that orthopaedic surgeons should play a role in the screening and appropriate identification of victims of IPV. We aimed to identify the knowledge, attitudes, and beliefs about IPV among orthopaedic surgeons who are members of the Orthopaedic Trauma Association.

Method: We surveyed members of the Orthopaedic Trauma Association to identify attitudes toward IPV by posting a survey on the Orthopaedic Trauma Association website for its membership to complete. The survey consisted of three sections:

the general attitude of the orthopaedic surgeon toward intimate partner violence,

Results: One-hundred-and-fifty-three orthopaedic surgeons responded. The majority of the respondents were male (99%) with practices in North America (96%). Surgeons underestimated the prevalence of IPV in their practices and communities and manifested several key misconceptions:

victims must be getting something out of the abusive relationships (16%);

In the past year, approximately half of the surgeons (50.8%) acknowledged identification of a victim of IPV; however, only 4.0% of respondents currently screened for IPV among female patients with injuries. Surgeons expressed concerns about lack of knowledge in the management of abused women (30%) Guidelines for the detection and management of IPV were uncommon in most surgeons’ practices (7.8%).

Conclusion: There is a strong rationale for addressing IPV as an issue that is relevant to the field of orthopaedic surgery just as it has been shown to be relevant to primary care, emergency medicine, and obstetrics and gynecology. Our study found that orthopaedic surgeons underestimated the prevalence of IPV in their practices, held multiple misperceptions about IPV, and demonstrated discomfort in identifying and treating IPV. Targeted educational programs on IPV are needed for surgeons who routinely care for injured women.

Purpose: The popularity of intramedullary nails (IMN) for trochanteric hip fractures has grown substantially with little supportive evidence that IMN are superior to conventional sliding hip screws (SHS). We aimed to assess the impact of SHS or IMN intramedullary nailing on functional outcomes and rates of re-operation in elderly patients with fractures.

Method: We conducted a multi-center, pilot randomized trial including three clinical sites across Sweden, Denmark, and Canada. We randomized 85 elderly patients with stable and unstable trochanteric hip fractures to either SHS or an IMN. The primary outcome, revision surgery, was independently adjudicated at one year. Secondary functional outcomes included the Parker Mobility Score (PMS), the Merle D’Aubigne Score, the Short Form-12 (SF-12) and the Euroquol-5D.

Results: Eighty five patients were enrolled. Fifteen patients died prior to the one year follow up. Across treatment groups, patients did not differ in age, gender and fracture type. The overall revision risk was 11.6% (8/69) and did not differ significantly between groups (IMN: 5; SHS: 3). Patients treated with IMN had significantly higher Merle D’Aubigne function subscores at 6 (p=0.01) and 12 months (p=0.05). Gamma3 nails approached significantly higher scores in the Parker mobility score at 6 (p=0.08) and 12 months (p=0.056). Non-significant differences were identified in the SF-12 and Euroquol-5D quality of life measures; however, in both scores, the Gamma3 nailed trended to higher scores than the sliding hip screw.

Conclusion: Our findings of early functional gains without increased risk of revision surgery support the increased popularity of IMN for the management of trochanteric hip fractures in elderly patients.

Purpose: Unbiased outcome assessment in orthopedic clinical trials has the potential to improve trial validity. The approaches used to limit bias in outcome assessment in orthopaedic trials remain unclear. The objective of this systematic review was to assess the reporting and process of outcomes assessment practices in the current orthopaedic trauma literature.

Method: We searched eight high-impact-factor medical and orthopaedic journals manually and using the MED-LINE electronic database for reports of randomized controlled trials published from 2005 to 2008 pertaining to the surgical treatment of trauma-related injuries. Two reviewers independently determined study eligibility and extracted relevant data from included trials.

Results: Of the 7910 citations identified during our search, 47 randomized controlled trials, which included a total of 4706 patients, met our inclusion criteria. Of 47 studies, 39 (83%) provided a statement to describe some process of outcome assessment and 29 (74%) reported using an unblinded individual as the outcome adjudicator. Four studies (10%) reported using a second assessor to verify outcome measurements, and three studies (8%) reported the use of an adjudication committee to reach endpoint decisions via consensus. No included study provided a rationale for the use of their chosen approach to adjudication. The most commonly adjudicated outcomes included fracture healing (15 studies), reoperation rate (6 studies), and general clinical assessment of post-operative complications and limb function (30 studies), mainly by orthopaedic surgeons. Blinding of outcome assessors was not performed or unclear in 38 studies (81%).

Conclusion: Despite the importance of the outcome assessment process in orthopedic trauma trials, key aspects of outcome assessment are insufficiently reported. This limits the ability of readers to assess the validity of published trials.

Purpose: Hip fractures are associated with a high rate of mortality and profound temporary and sometimes permanent impairment of independence and quality of life. While guidelines exist for the surgical treatment of hip fracture patients, the effect of surgical delay on mortality and other patient-important outcomes remains unclear. The objective of this systematic review and meta-analysis was to determine the effect of early surgery compared with delayed surgery on the risk of mortality, common postoperative complications, and length of hospital stay among elderly hip fracture patients.

Method: We searched MEDLINE and EMBASE for relevant prospective studies evaluating surgical delay in patients undergoing surgery for hip fractures published in all languages between 1966 and 2008. We identified additional studies through contacting experts, as well as hand searches of the bibliographies of relevant articles and the archives of orthopaedic annual meetings. Two reviewers independently assessed methodological quality and extracted relevant data. When necessary, we contacted authors for clarification of study design or to provide additional data. Data were pooled by use of a DerSimonian and Laird random-effects model based on the inverse variance method.

Results: Of 1917 citations identified, 16 observational studies, which included a total of 13,565 patients with complete mortality data, met our inclusion criteria. Irrespective of the cut-off for delay (24, 48, or 72 hours), earlier surgery (< 24, < 48, or < 72 hours) was significantly associated with a reduction in the risk of unadjusted one-year mortality (relative risk 0.55; 95% confidence interval, 0.40 to 0.75, p=0.0002) and adjusted mortality rates (relative risk 0.81; 95% confidence interval, 0.68 to 0.96, p=0.01). Earlier surgery also reduced in-hospital pneumonia (relative risk 0.59; 95% confidence interval, 0.37 to 0.93, p=0.02), pressure sores (relative risk 0.48; 95% confidence interval, 0.34 to 0.69, p< 0.0001) and hospital stay (weighted mean difference 9.95 days; 95% confidence interval, 1.52 to 18.39, p=0.02).

Conclusion: Earlier surgery reduced the risk of mortality, postoperative pneumonia, pressure sores, and length of hospital stay among elderly hip fracture patients suggesting that it may be warranted to reduce administrative delays whenever possible. However, potential residual confounding of observational studies may limit any definitive conclusions.

We conducted a systematic review and meta-analysis of randomised controlled trials comparing cross-linked with conventional polyethylene liners for total hip replacement in order to determine whether these liners reduce rates of wear, radiological evidence of osteolysis and the need for revision. The MEDLINE, EMBASE and COCHRANE databases were searched from their inception to May 2010 for all trials involving the use of cross-linked polyethylene in total hip replacement. Eligibility for inclusion in the review included the random allocation of treatments, the use of cross-linked and conventional polyethylene, and radiological wear as an outcome measure. The pooled mean differences were calculated for bedding-in, linear wear rate, three-dimensional linear wear rate, volumetric wear rate and total linear wear. Pooled risk ratios were calculated for radiological osteolysis and revision hip replacement. A search of the literature identified 194 potential studies, of which 12 met the inclusion criteria. All reported a significant reduction in radiological wear for cross-linked polyethylene.

The pooled mean differences for linear rate of wear, three-dimensional linear rate of wear, volumetric wear rate and total linear wear were all significantly reduced for cross-linked polyethylene. The risk ratio for radiological osteolysis was 0.40 (95% confidence interval 0.27 to 0.58; I² = 0%), favouring cross-linked polyethylene. The follow-up was not long enough to show a difference in the need for revision surgery.

Purpose: Domestic violence is the most common cause of nonfatal injury to women in North America and musculoskeletal injuries were the second most common manifestation of intimate partner violence (IPV). We aimed to identify the perceptions, attitudes, and knowledge about IPV among orthopaedic surgeons.

Method: Using a systematic random sample, we mailed surveys to 362 members of the Canadian Orthopaedic Association to identify attitudes towards IPV. The questionnaire consisted of three sections:

General Attitude of Orthopaedic Surgeon Towards IPV,

Up to 3 follow up mailings were performed to enhance response rates.

Results: Respondents (N = 186, response rate: 51%) consisted of 167 (91%) male orthopaedic surgeons, all actively practicing at the time of the survey. Most orthopaedic surgeons (95%) estimated that victims of IPV comprised less than 10% of their patients, the majority of whom (80%) believed it was exceedingly rare.

Conclusion: Orthopaedic surgeons grossly underestimated the prevalence of IPV in their communities. Discomfort with the issue and lack of knowledge led to misconceptions about IPV. The relevance of IPV to surgical practice was well supported but prevalence studies are needed change the current paradigm in orthopaedics.

Purpose: The choice of irrigating fluid and delivery pressure remains controversial. Identifying surgeons’ preferences in techniques and the rationale for their choices may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds.

Method: We mailed and delivered a cross-sectional survey using a sample-to-redundancy strategy to members of the Canadian Orthopaedic Association and attendees of an international fracture course (AO, Davos, Switzerland) to examine surgeons’ preferences in the initial management of open fracture wounds.

Results: Of the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, most surgeons surveyed, 676 (70.5%), favoured normal saline alone, however 16.8% used Bacitracin. Many surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound, however variation exists in what constituted high versus low pressure lavage. Surgeons supported the need for a clinical trial evaluating outcomes following both the use of different irrigating solutions as well as irrigating pressures [803 (84.8%) and 730 (77.6%) respectively].

Conclusion: The majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds.

In a meta-analysis of fourteen trials (N=1901 patients) in patients with displaced hip fractures, we identified significant reductions in the risk of revision surgery with internal fixation compared to arthroplasty. A trend towards increased mortality with arthroplasty was identified.

The purpose of this study was to determine the effect of arthroplasty (hemi-arthroplasty, bipolar arthroplasty and total hip arthroplasty) in comparison to internal fixation for displaced femoral neck fractures on rates of mortality and revision surgery

Arthroplasty for displaced femoral neck fractures, in comparison to internal fixation, significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time, and a possible increase in early mortality.

Over 220,000 fractures of hip occur per year in North America representing an annual seven billion dollar cost to the health care system. Current evidence suggests internal fixation may reduce mortality risk at the consequence of increased revision rates. A large trial is needed to resolve this issue.

We searched computerized databases (MEDLINE, COCHRANE and SCISEARCH) for published clinical studies from 1969–2002 and identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts and personal files. We found a non-significant trend toward an increase in the relative risk of dying with arthroplasty when compared to internal fixation (relative risk=1.27, 95% confidence interval, 0.84–1.92, p = 0.25; homogeneity p= 0.45). Arthroplasty appeared to increase the risk of dying when compared to pin and plate, but not in comparison to internal fixation using screws (relative risk= 1.75 vs 0.86, respectively, p< 0.05). Fourteen trials provided data on revision surgery (n=1901 patients). The relative risk of revision surgery with arthroplasty was 0.23 (95% confidence interval, 0.13–0.42, p = 0.0003, homogeneity p = < 0.01).

Introduction: Closed and open grade I (low energy) tibial shaft fractures are a common and costly event and optimal management for such injuries remains uncertain.

Methods: We explored costs associated with treatment of low energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree.

Results: From a governmental perspective the mean associated costs were USD $3 365 (standard deviation [SD] ± 1 425) for operative management by reamed intramedullary nailing, $5 041 (SD ± 1 363) for operative management by non-reamed intramedullary nailing, $5 017 (SD±1 370) for casting, and $5 312 (SD±1 474) for casting with therapeutic ultrasound. From a societal perspective the mean associated costs were ($12 449; SD±4 894) for reamed intramedullary nailing, ($13 266; SD±3 692) for casting with therapeutic ultrasound, ($15 571; SD±4 293) for operative management by non-reamed intramedullary nailing, and ($17 343; SD±4 784) for casting alone.

Interpretation: Our analysis suggests that, from an economical standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. There is preliminary evidence, from a societal perspective, that treatment of low energy tibial fractures with therapeutic ultrasound and casting may also be an economically-sound intervention.