Aims

It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital.

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR).

Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients.

The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients.

For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR.

The aim of this study was to investigate surgeons’ reported change of treatment preference in response to the results and conclusion from a randomized controlled trial (RCT) and to study patterns of change between subspecialties and nationalities.

Two questionnaires were developed through the Delphi process for this cross-sectional survey of surgical preference. The first questionnaire was sent out before the publication of a RCT and the second questionnaire was sent out after publication. The RCT investigated repair or non-repair of the pronator quadratus (PQ) muscle during volar locked plating of distal radial fractures (DRFs). Overall, 380 orthopaedic surgeons were invited to participate in the first questionnaire, of whom 115 replied. One hundred surgeons were invited to participate in the second questionnaire. The primary outcome was the proportion of surgeons for whom a treatment change was warranted, who then reported a change of treatment preference following the RCT. Secondary outcomes included the reasons for repair or non-repair, reasons for and against following the RCT results, and difference of preferred treatment of the PQ muscle between surgeons of different nationalities, qualifications, years of training, and number of procedures performed per year.

Of the 100 surgeons invited for the second questionnaire, 74 replied. For the primary outcome, 6 of 32 surgeons (19%), who usually repaired the PQ muscle and therefore a change of treatment preference was warranted, reported a change of treatment preference based on the RCT publication. Of the secondary outcomes, restoring anatomy was the most common response for repairing the PQ muscle.

The majority of the orthopaedic surgeons, where a change of treatment preference was warranted based on the results and conclusion of a RCT, did not report willingness to change their treatment preference.

In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery.

A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals.

Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who were vs were not using opioids pre-operatively (respectively); acute adverse events (39.1% vs 38.6%), acute significant adverse events (5.3% vs 5.7%), late adverse events: (6.9% vs 6.6%), total significant adverse events: (12.5% vs 12.4%), discharge to inpatient rehab (86.4% vs 88.6%), length of hospital stay (5.9 (3.0) vs 5.6 (3.0) days), 6-month post-op Oxford Score (38.8 (8.9) vs 39.5 (7.9)), 6 months post-op EQ-VAS (71.7 (20.2) vs 76.7 (18.2), p<0.001), success post-op described as “much better” (80.2% vs 81.3%).

Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes.

Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events.

Obesity is associated with worse outcomes following total knee/hip arthroplasty (TKA/TKA). This study aimed to determine the feasibility of a dietitian-led low-inflammatory weight-loss program for people with obesity awaiting arthroplasty.

Quasi-experimental pilot study enrolled people with obesity waitlisted for primary TKA/THA into ‘usual care’ (UC) or weight-loss (low-inflammatory diet) program (Diet). Recruitment occurred between July 2019 and February 2020 at Fairfield and Campbelltown Hospitals. Assessments at baseline, pre-surgery, time of surgery and 90-days following surgery included anthropometric measurements, patient-reported outcomes, serum biomarkers and 90-day postoperative complication rate.

97 people consented to the study (UC, n=47, mean age 67, BMI 37, TKA 79%; Diet, n=50, mean age 66, BMI 36, TKA 72%). Baseline characteristics indicated gross joint impairments and poor compliance with a low-inflammatory diet. Study feasibility criteria included recruitment rate (52%), proportion of diet patients that improved compliance to low-inflammatory diet by ≥10% (57%) and had ≥60% attendance of dietitian consultations (72%), proportion of patients who undertook serum biomarkers (55%).

By presurgery assessments, the diet group had more patients who cancelled their surgery due to symptom improvement (4 vs 0), reduced waist-circumference measurements, increased compliance with the Low-Inflammatory diet and preservation of physical activity parameters. More usual care participants experienced at least one postoperative complication to 90-days (59% vs 47%) and were discharged to inpatient rehabilitation (21% vs 11%). There was no difference in weight change, physical function, and patient-reported outcome measures from pre-surgery to 90-days post-surgery, and length of hospital stay.

Using pre-determined feasibility criteria, conducting a definitive trial is not feasible. However, intervention audit demonstrated high intervention fidelity.

Pilot data suggest our program may promote weight loss but the clinical effects for most are modest. Further research utilising a stronger intervention may be required to assess the effectiveness of a pre-arthroplasty weight-loss intervention.

In this study we compare survivorship and patient reported outcome measures in robotically assisted versus conventional Total Hip Arthroplasty (THA).

This paper investigates the hypothesis that implant survival and PROMS following THAs performed with robotic assistance were not different to outcomes following conventional THAs.

Data included all patients undergoing THA for osteoarthritis between 19 April 2016 and 31 December 2020. Analysis of PROMS outcomes was restricted to those who had completed PROMS data preoperatively and at 6 months postoperatively.

There were 157,647 procedures, including 3567 robotically assisted procedures, available for comparison of revision rates. 4557 procedures, including 130 robotically assisted procedures, had PROMS data available. The revision rate of primary THA performed with robotic assistance was not statistically different from THA performed by conventional methods (4 year cumulative percent revision 3.1% v 2.7%; HR = 1.05, p=0.67). The Oxford Hip Score, VAS for pain and the EQ-VAS score for overall health showed no statistically significant difference between the groups. The EQ-5D Utility Score showed an improved score (median score 1 v 0.88; OR = 1.58, p=0.007) for the robotically assisted group compared to the conventional group.

Robotic assisted THA was not associated with significant improvement in early revision or joint-specific PROMs. The findings may have been biased, in either direction, by unmeasured patient, surgeon, hospital and prosthesis factors. The findings (including the difference in health-related quality of life) may have also been influenced by lack of blinding. Future research should include methods to minimise these biases.

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR).

Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients.

The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients.

For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR.

Aims

The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA).

Emerging evidence has linked the long-term use of alendronate (fosamax) with subtrochanteric insufficiency fractures. However, findings to date have been anecdotal. The aims of this study were to determine the incidence of subtrochanteric insufficiency fractures and identify whether they were more prevalent following the introduction of alendronate in Australia.

All patients that presented between January 2007 and February 2009 with low- energy subtrochanteric fracture were identified. Similar data were collected between January 1995 and February 1997 as this was immediately prior to introduction of alendronate in Australia. The radiographs were examined for failure due to pre- existing insufficiency fracture. Characteristic findings were a transverse fracture line on the tension side of the femur with lateral cortical thickening immediately adjacent to the fracture. Relevant details from the history were recorded. We also separately identified all patients that presented between 2007 and 2009 with a proximal femoral fracture and determined the proportion taking alendronate.

One hundred and seventeen patients with low-energy subtrochanteric fracture were included. Seventy-nine patients presented between 2007 and 2009 and 38 presented between 1995 and 1997. Forty-one of the 79 (52%) patients were identified as having radiograph findings suggestive of underlying insufficiency fracture, whilst none were identified prior to the introduction of alendronate. Of the 41 patients with subtrochanteric insufficiency fracture, 40 (98%) had been taking alendronate and one had been taking risedronate. Twenty-nine of the 41 (71%) complained of prodromal pain in the affected femur. Eighteen of the 41 (44%) demonstrated subtrochanteric insufficiency changes on the contralateral side and 9 of 41 (22%) sustained spontaneous non-traumatic fracture during activities of daily living. Of the 38 patients without insufficiency changes, 12 (32%) had been taking alendronate. Alendronate use was therefore strongly suggestive of insufficiency fracture (sensitivity = 98%, specificity = 84%, PPV = 77%, NPV = 99%, LR+ = 6). The mean duration of alendronate use in those with insufficiency fracture was 7.1 years (95% CI, 6.6-7.6 years). The mean duration in those without was 3.2 years (95% CI, 2.6-3.8 years, P<0.0001). Three hundred and ninety eight patients presented with a low-energy proximal femur fracture between 2007 and 2009. Of these, only 52 (13%, P<0.0001) were taking alendronate.

This is the largest study in the literature on subtrochanteric insufficiency fractures and alendronate therapy. Confirming recent reports, alendronate use was strongly suggestive of subtrochanteric insufficiency fracture. Our findings provide the most compelling evidence to date of the potential long-term sequelae of alendronate but more research is needed before definitive conclusions can be made.

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures.

With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046).

At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group.

Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function.

Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall.

Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and intramedullary fixation (7%). Shoulder surgeons were more likely to operate (p<0.001). For an undisplaced Weber B lateral malleolus fracture, respondents selected plaster cast or boot (59%), lateral plating (31%), posterior plating (9%) and no splinting (2%). For a displaced Colles fracture in an older patient, respondents selected plating (47%), Kirschner wires (28%), cast/splint (23%) and external fixation (1%). Less experienced (p<0.001) and hand surgeons (p=0.024) were more likely to operate. For a two-part neck of humerus fracture in an older patient, respondents selected non-operative (74%), locking plate (14%), and hemiarthroplasty (7%). Shoulder surgeons were more likely to operate (p<0.001). Accounting for all answers in multiple regression modeling, it was found that more experienced surgeons (>15 years) were 25% less likely to operate (p=0.001). Overall, there was no difference among sub-specialties, or whether a surgeon participated in an on-call roster.

Considerable practice variation exists among orthopaedic surgeons in the approach to common orthopaedic problems. Surgeons who identify with a sub-specialty are more likely to manage conditions in their area of interest operatively, and more experienced surgeons are less likely to recommend surgical management.

Thromboprophylaxis for venous thromboembolism (VTE) after elective arthroplasty remains controversial. Previous surveys have shown considerable variation amongst orthopaedic surgeons, and the topic is still being debated. Chest physicians recently advocated that randomised data demonstrating a risk reduction with long- established thromboprophylaxis have been ignored by orthopaedic surgeons. We present the current thromboprophylaxis practice amongst AOA members performing elective hip and knee replacements and discuss its rationale.

All orthopaedic surgeons in the AOA were asked to complete a one page postal questionnaire asking for information regarding: whether they performed elective hip or knee arthroplasty, which methods of mechanical and/or chemical prophylaxis were routinely used, the time frame in ceasing thromboprophylaxis, the motive in using thromboprophylaxis, and whether thromboprophylaxis guidelines released by the AOA or RACS would be helpful in their orthopaedic practice.

Responses from the survery are currently being collected and analysed. These results will be ready for presentation at the AOA conference.

The results of the survey will be presented in addition to a discussion of the rationale behind current use of post-operative thromboprophylaxis for elective hip and knee arthroplasty and a need for clinical guidelines.

Patella fractures constitute 1% of all fractures and may disrupt the extensor mechanism of the knee. The mainstay of treatment for most patella fractures is operative fixation; however, patients with intact extensor mechanisms may be treated with splinting. We describe a series of patients with patella fractures managed non- operatively, without restricted weight bearing or splinting.

A consecutive series of 21 patients presenting with a patella fracture to two metropolitan hospitals were included in this study. All patients had an intact extensor mechanism but no distinction was made on age or fracture type. All patients were treated non-operatively with analgesia, were allowed to fully weight-bear and were not splinted. A retrospective review of the case notes was performed and data was collected with phone interview. The main outcome measure was the Western Ontario and McMaster Universities

Osteoarthritis (WOMAC) index, which has a maximum (worst) possible score of 240, and which provides an aggregate score of pain, stiffness and function. Mean time at follow up was 24 months (range 5–49 months). WOMAC scores were excellent (mean=18 of possible maximum 240; range 0–84). Only one patient had a significant complication related to their fracture (deep venous thrombosis), which was detected during hospital admission. Most patients had returned to usual work (9/14). No patients required operative fixation. There was no association between adjusted WOMAC score and age, sex, compensation status, time of follow up, or whether the patient had a significant ipsilateral injury. Patients who had returned to work (p=0.02) or who had lower levels of education (p=0.03) had better WOMAC scores.

Management of patella fractures with an intact extensor mechanism does not require restricted weight bearing or splinting.

Tibial shaft fractures have a high incidence of delayed and non-union, often requiring multiple procedures. Pulsed electromagnetic field (PEMF) stimulation is a safe and effective treatment for tibial non union but little is known about the efficacy of PEMF in preventing non-union in acute fractures.

Between August 2005 and December 2008, eligible patients presenting at six major metropolitan hospitals with acute tibial shaft fractures (AO classification 4-2) were included. Participants were randomised by an independent allocation centre to identical active or inactive PEMF devices, both prescribed to be worn ten hours daily for twelve weeks. Baseline data were collected, and patients and surgeons were surveyed serially via post and/or phone at three, six and twelve months. Participants, data collectors and data analysts were blinded. The main outcome was any surgical intervention for delayed/non union.

Data from 150 patients (76 active and 74 inactive) were available for analysis (12 month follow up 78%). There was no between-group difference in age, gender, mechanism of injury, open grade, smoking status, or compliance with the device (hours of use). Overall compliance was moderate (5.7 hours daily use). Fifteen of 76 (20%) of active device patients required surgery for delayed/non-union vs. 8 of 74 (11%) in the placebo group; odds ratio of surgery=2.03, p=0.13, 95% CI 0.80 to 5.12. An intention to treat analysis adjusted for open grade and hours the device was used showed an odds ratio of requiring surgery of 1.78 (p=0.24, 95% CI 0.68 to 4.64). A sub-group analysis of 80 compliant patients (defined a priori as a minimum average of six hours daily use) was performed. Nine of 35 (26%) patients with an active device required surgery for delayed/non-union vs. 3 of 45 (7%) in the placebo group; odds ratio of surgery=7.60 (p=0.017, 95% CI 1.43 to 40.24).

Based on these unexpected initial results, PEMF stimulation does not prevent revision surgery for delayed/non-union in acute fractures of the tibial shaft.

This study aims to explore the trend in spine fusion surgery in Australia over the past 10 years and to explore the possible influence of health insurance status (private versus public) on the rate of surgery.

Data pertaining to the rate of lumbar spine fusion from 1997 to 2006 were collected. Data on publicly performed procedures in NSW were obtained from Inpatient Statistics Collection of NSW Health, and data on privately performed procedures were obtained from Medicare Australia Statistics. Population data was obtained from the Australian Bureau of Statistics. Data on total hip and total knee arthroplasties performed were collected to provide a comparator. Health insurance coverage was also investigated to control for insurance status, this data was obtained from the Private Health Insurance Administration Council.

There has been a slowly declining trend in the number of publicly performed spinal fusion procedures over the past 10 years, falling by 63% from 1997 to 2006 in NSW. In comparison, privately performed spinal fusion procedures have increased by 166% over the same 10 year period. Compared to spine fusion, the rates of total hip and total knee replacement procedures in the public sector of NSW have fallen by smaller proportions (58.9%% and 42.1%, respectively) over the same 10 year period. The increase in privately performed joint replacements has been less than that seen for spine fusion, with increases of 120% and 74%% for knee arthroplasties and hip arthroplasties, respectively.

In 2006, spine fusion surgery was 10.8 times more likely to be done in the private sector than in the public sector, compared to corresponding figures of 4.2 times and 3.0 times for knee replacement and hip replacement, respectively.

Our study has demonstrated that there is a disproportionately high rate of spine fusion procedures performed in the private sector. Possible explanations for this difference include: over servicing in the private sector, under servicing in the public sector, differences in medical referral patterns, surgeon and patient preferences, and financial incentives.

To examine surgeon supervision in orthopaedic trauma in Australia.

An Australia-wide cross-sectional survey was performed using a mass electronic mail-out distributed to members of the Australian Orthopaedic Association. Rates of supervision for six common operations (tibial nailing, femoral nailing, hip hemiarthroplasty, hip fracture fixation, ankle fracture fixation, paediatric supracondylar fracture). Other factors recorded included; payment type, hospital type, state, seniority, theatre availability, and trauma load. Responses were tabulated and analysed using SAS software.

21.9% of surgeons completed the survey, out of 739 surgeons who were sent the e-mail invitation. Univariate analysis showed increased supervision to be associated with; more junior consultants, regional and rural hospitals, state (NSW and Victoria), and method of payment (fee for service). However, multivariate analysis showed that fee for service payment (compared to sessional payment) was the only factor significantly associated with increased supervision for all operations surveyed.

Higher remuneration for surgeons may increase supervision rates of trainees.

We aimed to examine the influence of nursing home residency on mortality after sustaining an acute hip fracture in patients presenting to a metropolitan trauma centre. A prospective study of all adults aged 65 years and over who presented to a single tertiary referral hospital for management of a fracture of the proximal femur between July 2003 and September 2006. Residential status was obtained at admission. Patients were followed up to September 2007. Relative risk values for mortality were calculated comparing nursing home residents with non-nursing home residents. Survival analysis was performed.

Relative risk of death was higher in nursing home patients compared to non-nursing home patients. This was particularly so in the first 30 days (RR 1.9). Survival analysis showed that 25% of patients in the nursing home group died by 96 days post-injury, compared with 435 days post-injury in the non-nursing home group. The age-adjusted hazard ratio for death in nursing home patients was 1.5 (95% CI: 1.1–2.1), however the effect of nursing home status decreased over the first 12–24 months.

Nursing home residence confers an increased risk of death following hip fractures, especially in the immediate post-injury period. However, the relative risk of death decreased over time. This study provides some indication of the mortality risk in an easily definable population, without requiring an alternative assessment of comorbidities.

Rates of operative fixation for clavicle fractures have been increasing over recent years, but non-operative treatment remains the most common treatment. However, the reported results of case series of non-operatively and operatively treated clavicle fractures show considerable variation, making comparison difficult.

Non-operative treatment leads to unsatisfactory results in approximately 3 – 10% of cases, sometimes requiring delayed surgical intervention. Recent studies exploring predictors of poor results after non-operative treatment have shown that fracture displacement is a significant predictor of poor outcome. However, fracture comminution, angulation, shortening, smoking, age, and fracture type and location are not consistently associated with worse outcomes. This has lead to increased interest in surgical fixation for displaced fractures.

Prior to the large randomised trial by the Canadian Orthopaedic Trauma Society (COTS), controlled trials comparing surgery to non-operative treatment provided no significant support for surgical fixation. The COTS study provides some evidence for plating displaced mid-shaft fractures, however, partly due to methodological issues, recent reviews of the topic have concluded that additional, more rigorous studies are required to confirm the findings of the COTS trial.

Intramedullary fixation is also popular, but it does not have the weight of evidence of plate fixation.

Patient satisfaction has only recently gained attention as an outcome measure in orthopaedics, where it has been reported for joint replacement surgery. Little has been published regarding predictors of patient satisfaction in orthopaedic trauma. This study aims to explore the predictors of patient satisfaction, and of surgeon satisfaction, after orthopaedic trauma.

Adult patients admitted to hospital with fractures after motor vehicle trauma were surveyed on admission, and at six months. Demographic, injury, socio-economic and compensation-related factors were measured. The two outcomes were satisfaction with progress of the injury, and satisfaction with recovery. The treating surgeons were also surveyed at six months to determine surgeon satisfaction with progress, and recovery (using the same questions), and the presence or absence of fracture union and any complications. Multivariate analysis was used to determine significant predictors of satisfaction for both groups, and satisfaction rates were compared between surgeons and patients using multivariable analysis.

Of 306 patients recruited, 232 (75.8%) returned completed questionnaires, but only 141 (46.1%) surgeons responded. Patients rated their satisfaction with progress and recovery as 74.6% and 44.4%, respectively, whereas surgeon-rated satisfaction with progress and recovery was 88.0% and 66.7%, respectively (p< 0.0001). Significant predictors of patient dissatisfaction were: blaming others for the injury, being female, and using a lawyer. Patient-rated outcome was not significantly associated with objective injury or treatment factors. The only significant predictor of surgeon dissatisfaction was fracture non-union.

Orthopaedic surgeons overestimated the progress of the injury and the level of recovery compared to patients’ own ratings. Surgeons’ ratings are influenced by objective, treatment-related factors, whereas patients’ ratings were not. Measures of outcome commonly used b y orthopaedic surgeons, such as fracture union, do not predict patient satisfaction.

Introduction and Aims: Subtrochanteric femoral fractures are associated with high rates of non-union and implant failure, regardless of the method of fixation. This study aims to compare closed intra-medullary nailing without anatomic reduction to open reduction and internal fixation using a fixed angle device, for subtrochanteric femur fractures.

Method: All skeletally mature patients admitted to two metropolitan trauma centres with subtrochanteric femur fractures were included in this study. Patients were randomised to intra-medullary nailing (IM) or internal fixation with a 95-degree blade plate (BP). Randomisation was concealed. The IM group were treated by closed insertion of a proximal femoral nail without anatomic reduction. The BP group were treated with open anatomic reduction and rigid fixation using a 95-degree angled blade plate. Bone grafting was at the discretion of the operating surgeon. All patients were mobilised non weight bearing for 12 weeks or until callus was seen on radiographs.

Results: A total of 41 patients (20 IM and 21 BP) with a minimum follow-up of six months have been included. There was no significant difference between the two treatment groups with regard to age, time to surgery, length of procedure, blood transfusion requirements, length of stay, or fracture classification (Seinsheimer). The fixation failure rate was 29% (six patients) in the BP group. There were no fixation failures in the IM group. The difference is statistically significant (p< 0.05). An increased infection and mortality rate was noted in the IM group, although it was not statistically significant.

Conclusion: Internal fixation of subtrochanteric femur fractures with a 95-degree angled blade plate is associated with increased implant failure and revision compared to closed intra-medullary nailing using a proximal femoral nail.