The purpose of this study was to define the risk and incidence of eventual ankle arthroplasty or fusion after documented ankle fracture in a large cohort, and compare that rate to matched healthy patients from the general population.

The Ontario health insurance plan (OHIP) physician billing database, Institute for Clinical Evaluative Sciences (ICES) Physician Database, the Canadian Institute for Health Information (CIHI) databases, Discharge Abstract Database (DAD) and Same Day Surgery (SDS) were used to identify patients treated surgically and non-surgically for ankle fractures. Each patient was matched to four individuals from the general population (13.5 million) with no documented prior treatment for ankle fracture, according to age, sex, income, and urban/rural residence. Fusion and replacement incidence was compared using time-to-event analysis (Kaplan-Meier). A Cox Proportional Hazards model was used to explore the influence of patient, provider and surgical factors on time to surgery.

We identified 45,444 (58.8% female, mean age 48.7 years) and 140, 629 (53.9% female, mean age 47.1 years) patients who had undergone open reduction internal fixation (ORIF) or non-operative management of an ankle fracture (NOA), respectively. Among ORIF patients, n=237 (0.5%) and n=69 (0.15%) patients underwent fusion or arthroplasty after a median 2.8 and 6.9 years, respectively. Among non-operatively treated ankle fractures, n=198 (0.14%) and n=36 (0.03%) patients underwent fusion or arthroplasty after a median of 3.2 and 5.6 years, respectively. Surgical treatment (vs. non-operatively treated fracture), older age, greater co-morbidity and a history of infection post fracture significantly increased the risk of eventual fusion or arthroplasty (HR 3.6 (3.1–4.3), p < 0 .001, HR 1.01 (1.01–1.02), p=0.009, HR 1.2 (1.1–1.3), p < 0 .001, HR 11.3 (6.8–18.7), p < 0 .001, respectively). Compared to matched controls, the risk of fusion/arthroplasty was not independent of time, following an exponential decay pattern. ORIF patient risk was 20 times greater than the general population in the first three years post-ORIF, and approached the risk of non-operatively treated patients (HR 4.5 (95CI: 3.5–5.8), p < 0 .0001) by approximately 14 years out from injury on time and comorbidity adjusted KM curves.

Rates of fusion/arthroplasty are very low after ORIF and non-operative treatment of an ankle fracture in the general population of a public healthcare system. Utilization patterns suggest fusion is more common earlier, and arthroplasty remote, which may be a factor of patient age, injury severity, and complications from initial injury/surgery. Patients who underwent ORIF have >20 times the risk of fusion/arthroplasty in the short-term, however, the risk decreases over time eventually approaching that of non-operatively treated patients (∼4.5x the general population) when compared to non-fractured controls.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations).

Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions.

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion.

MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden.

Patient satisfaction is an important measure of patient-centered outcomes and physician performance. Given the continued growth of the population undergoing surgical intervention for osteoarthritis (OA), and the concomitant growth in the associated direct costs, understanding what factors drive satisfaction in this population is critical. A potentially important driver not previously considered is satisfaction with pre-surgical consultation. We investigated the influence of pre-surgical consultation satisfaction on overall satisfaction following surgery for OA.

Study data are from 1263 patients who underwent surgery for hip (n=480), knee (n=597), and spine (n=186) OA at a large teaching hospital in Toronto, Canada. Before surgery, patient-reported satisfaction with information received and degree of input in decision-making during the pre-surgical consultation was assessed, along with expectations of surgery (regarding pain, activity limitation, expected time to full recovery and likelihood of complete success). Pre- and post-surgery (6 weeks, and 3, 6, and 12 months) patients reported their average pain level in the past week (0–10, 10 is worst). At each follow-up time-point, two pain variables were defined, pain improvement (minimal clinically important difference from baseline ≥2 points) and ‘acceptable’ pain (pain score ≤ 3). Patients also completed a question on satisfaction with the results of the surgery (very dissatisfied/dissatisfied/somewhat satisfied/very satisfied) at each follow-up time point. We used multilevel ordinal logistic regression to examine the influence of pre-surgery satisfaction with consultation on the trajectory of satisfaction over the year of recovery controlling for expectations of surgery, pain improvement, acceptable pain, socio-demographic factors (age, sex, and education), body mass index, comorbidity, and depressive symptoms (Hospital Anxiety and Depression Scale).

Mean age of the sample was 65.5 years, and over half (54.3%) were women. Overall, 74% and 78.9% of patients were satisfied with the information received and with the decision-making in the pre-surgical consultation, respectively, no significant differences were found by surgical joint (p=0.22). Post-surgery, levels of satisfaction varied very little over time (6 weeks: 92.5% were satisfied and 66.4% were very satisfied, 1 year: 91.1% were satisfied and 65.6% were very satisfied). Results from a model including time, surgical joint, satisfaction with consultation and control factors indicated that being satisfied with the information received in the pre-surgical consultation was associated with higher odds of being more satisfied after surgery (OR: 1.2, 95% CI: 1–1.4). Additionally, spine and knee patients were more likely to be dissatisfied than hip patients (OR: 3.2, 95% CI: 2.1–4.9 and OR: 2.5, 95% CI: 1.8–3.4 for spine and knee patients respectively). Achieving pain improvement (OR: 1.7, 95% CI: 1.3–2.4) and acceptable pain (OR: 2.5, 95% CI: 1.6–3.9) were both significantly associated with greater satisfaction. Pre-operative expectations were not significantly associated with post-surgery satisfaction.

Findings highlight the important role of pre-surgery physician-patient communication and information on post-surgery satisfaction. This points to the need to ensure organizational provisions that foster supportive and interactive relationships between surgeons and their patients to improve patients' satisfaction. Findings also highlight that early post-recovery period (i.e. <= 3 months) as a key driver of longer-term satisfaction.

Purpose

Femoral nerve blockade (FNB) can provide prolonged postoperative analgesia and facilitate rehabilitation following major knee surgery while minimizing opioid-related adverse effects. However, anecdotal data have implicated FNB in post-operative falls, presumably due to a block-related reduction in quadriceps strength. Age, gender and knee replacement surgery have also been previously identified as risk factors for falls in the acute postoperative orthopaedic inpatient setting. We hypothesized that the use of FNB would be an independent predictor of an inpatient fall following total knee replacement (TKR).

Purpose

Elective ACLR is indicated for symptomatic instability of the knee. Despite being a common procedure, there are numerous surgical techniques, graft and fixation choices. Many have been directly compared in randomized trials and meta-analyses. The typical operation is arthroscopic-assisted, uses autograft tendon and screw fixation. Research in elective joint replacement surgery has demonstrated an inverse relationship between surgeon volume and revision and complication rates. How patient demographics, provider characteristics and graft/fixation choices influence ACLR revision rates has not been reported on a population level. We hypothesized that ACLR using tendon autograft and screw fixation performed by high volume surgeons will have the lowest rate of revision. In contrast, the risk of contralateral ACLR in the same cohort will be influenced only by patient factors.

Purpose

Factors that contribute to early and late re-operation after cruciate reconstruction (CR) have not been evaluated on a population level in a public health system. After surgery patients are at risk for knee stiffness, infection or early graft failure prompting revision. Long-term, ipsilateral revision CR, contralateral CR and potentially even joint replacement may occur. Population research in total joint replacement surgery has demonstrated an inverse relationship between complication/failure rates and surgeon procedural volume. We hypothesized that in Ontario, younger patient age and lower surgeon volume would increase the risk of short and long-term re-operation after CR.