Canadian Orthopaedic Association Research Articles

Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership.

The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design. A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal. 191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%). The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.

Gender Representation in Major Orthopaedic Surgery Meetings: A Quantitative Analysis.

Orthopaedic surgery suffers from gender disparity, and annual conferences are visible opportunities to quantify gender representation within a field. Therefore, the purpose of this manuscript was to investigate the prevalence of female speakers and moderators, and male-only panel sessions, at 10 major Orthopaedic Surgery meetings. Conference programs and details of faculty moderating or presenting in 10 Orthopaedic Surgery annual meetings in 2021 were retrieved. Conferences were selected with the aim of size and diversity in subspecialty topics and included American Association of Hip and Knee Surgeons, American Association for Hand Surgery, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Canadian Orthopaedic Association (COA), European Federation of National Associations of Orthopaedics and Traumatology, North American Spine Society, Orthopaedic Research Society (ORS), Orthopaedic Trauma Association, and Pediatric Orthopaedic Society of North America (POSNA). Primary outcomes included percentage of female chairs and speakers and percentage of male-only panels, while secondary outcomes included number of publications, number of citations, and H-indexes of faculty. Further subgroup comparisons were performed between male-only panels and non-male-only panels and female members and male members. Of 207 included sessions, 121 (58.5%) were male-only panels and 150 (12.6%) of 1,188 faculty members were women. Conferences organized by the COA, ORS, and POSNA had higher percentages of female representation, while spine surgery and adult hip/knee reconstruction sessions had more than 70% male-only panels and fewer than 10% female members. There were no significant differences between male members and female members regarding years of practice; however, male members were more likely to hold the title of professor (p < 0.001). Male members and female members stratified by quartiles of publications, citations, and H-indexes, moderated or participated in similar numbers of sessions, indicating an absence of selection bias. There is a high prevalence of male-only panels (58.5%) and an overall lack of female representation (12.6%) in 10 major Orthopaedic Surgery meetings. Male members and female members from these conferences were found to have similar qualifications academically. Specific strategies such as the elimination of male-only panels, selecting diverse conference organizers, and forming conference equity, diversity, and inclusion committees can help achieve cultural change. Level V.

A Survey of Treatment Trends for Acute Quadriceps Tendon Ruptures Among North American Surgeons.

Background:To date, little clinical evidence exists to support a specific surgical technique or postoperative rehabilitation protocol for quadriceps tendon ruptures. With a lack of evidence-based superiority, assessment of clinical practices and surgeon preferences is pertinent.Purpose:To describe the current surgical technique and rehabilitation preferences among members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine pertaining to acute quadriceps tendon rupture.Study Design:Cross-sectional study.Methods:Orthopaedic staff members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine were invited to complete an internet-based survey composed of 26 questions assessing current trends in the management and rehabilitation of acute quadriceps tendon rupture. Survey questions were developed after a thorough review of current literature. Survey responses were analyzed and reported using descriptive statistics (absolute values, frequencies, and percentages) where appropriate. Statistical comparisons and contrasts between Canadian and American surgeons were made using chi-square analyses and Student t tests.Results:A total of 264 surgeons participated in the survey (136 Canadians; 128 Americans). Canadian surgeons were more likely to obtain a preoperative ultrasound as compared with Americans (43.0% vs 6.7%; P < .00001), while American respondents were more likely to obtain magnetic resonance imaging scans (65.8% vs 10.2%; P < .00001). The transosseous drill hole technique was the most commonly utilized (70.2%); the suture anchor technique was used 20.6% of the time. Canadian respondents trended toward a higher use of transosseous tunnels; however, this was not statistically significant (75.8% vs 64.2%; P = .068). American respondents were more likely to utilize suture anchors (27.5% vs 14.1%; P = .0096). Most respondents advanced range of motion goals stepwise in 2-week intervals of 30° (Canadians, 54.0% vs Americans, 58.5%; P = .3091); timing of range of motion initiation varied.Conclusion:Among North American surgeons who responded to this study, the transosseous technique was the most commonly used, and range of motion was generally advanced in a 2-week stepwise fashion. We found several differences in practice between Canadian and American respondents, including the type of preoperative imaging and the frequency of using the suture anchor technique.

Prevalence of gender-based and sexual harassment within orthopedic surgery in Canada.

Background:Gender-based and sexual harassment are prevalent in the medical profession. We aimed to quantify the prevalence of such behaviours within orthopedic surgery in Canada and to identify any risk factors for experiencing gender-based or sexual harassment in the workplace.Methods:In collaboration with the Canadian Orthopaedic Association, we conducted a Canada-wide email questionnaire survey in June 2019 of all orthopedic surgeons registered with the Canadian Orthopaedic Association and the Canadian Orthopaedic Residents’ Association. The development of our questionnaire was informed by a review of the literature and published surveys on gender-based and sexual harassment, and consultation with researchers in intimate partner violence. We conducted a multivariable logistic regression analysis to identify risk factors for harassment.Results:Of the 1783 surgeons invited to participate, 465 returned the questionnaire (response rate 26.1%); the response rate was 48.1% for females and 22.1% for males. Overall, 331/433 respondents (76.4%, 95% confidence interval [CI] 72%–80%) and 315/423 respondents (74.5%, 95% CI 70%–78%) reported having experienced at least 1 occurrence of gender-based and sexual harassment, respectively. Women were significantly more likely than men to have experienced both gender-based and sexual harassment (odds ratio [OR] 16.2, 95% CI 4.8–54.0, and OR 2.2, 95% CI 1.2–4.0, respectively). Respondents who identified as nonwhite were significantly less likely than those who identified as white to have experienced gender-based harassment (OR 0.5, 95% CI 0.3–0.99).Conclusion:The prevalence of gender-based and sexual harassment is high within Canadian orthopedic surgery, and women are at highest risk for experiencing harassment. The results may provide the impetus for orthopedic societies to develop action plans and to re-examine and enforce policies to address these damaging behaviours appropriately.

Perpetrators of Gender-Based and Sexual Harassment in the Field of Orthopaedic Surgery.

Background:The prevalence of gender-based and sexual harassment in the field of orthopaedic surgery in Canada is high. Previous research in other jurisdictions has identified the most common perpetrators of harassment to be senior surgeons or directors. We aimed to identify the most frequent perpetrators of gender-based and sexual harassment in orthopaedic surgery in Canada.Methods:We conducted a Canada-wide survey of all orthopaedic surgeons registered with the Canadian Orthopaedic Association and the Canadian Orthopaedic Residents’ Association. The development of our 116-item questionnaire was informed by a review of the literature and other published gender-based and sexual harassment surveys. Descriptive analyses, including frequency counts with associated 95% confidence intervals (CIs), are reported for all data.Results:Of the 465 survey respondents, the median age was 43 years (interquartile range, 35 to 59) and respondents were most commonly male (72%), White (81%), married (77%), and staff orthopaedic surgeons (68%). Peers were identified as the most common perpetrators of gender-based harassment (55%, 95% CI, 50 to 59), and patients were identified as the most common perpetrators of sexual harassment (48%, 95% CI, 43 to 52). Women were more likely to report direct supervisors or patients as the perpetrators of gender-based and sexual harassment, and men reported peers as the most common perpetrators.Conclusion:Orthopaedic surgery peers and patients are the most commonly reported perpetrators of gender-based and sexual harassment in Canada. The results of this study may be helpful to institutions in designing and focusing educational programs and/or policies and procedures to help reduce harassment incidents in the training and work environment.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk. An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated. A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information. HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.

Management of Ankle Fractures With Syndesmotic Disruption: A Survey of Orthopaedic Surgeons.

Introduction: With no current “gold standard” fixation strategy for syndesmotic injuries and differences in preferred preoperative and intraoperative diagnostic techniques and criteria, methods of reduction, fixation constructs, and postoperative management, the goals of this study were to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption, as well as to identify surgeon demographics predictive of syndesmotic management techniques.Methods: This study was conducted as a web-based survey of foot and ankle fellowship-trained surgeons, Orthopaedic Trauma Association (OTA) members, and Canadian Orthopaedic Association (COA) members. The survey, sent and completed via the HIPAA-compliant Research Electronic Data Capture (REDCap) system, consisted of 18 questions: 6 surgeon demographic questions and 12 specific syndesmotic management questions regarding perioperative protocols and syndesmotic fixation construct techniques.Results: One hundred and ten orthopaedic surgeons completed our survey. Years of practice and type of fellowship were found to be the variables that influenced perioperative syndesmotic management strategies the most, while a number of fractures operated on per year, country of practice, and practice setting also influenced management decisions. Additionally, 59% (65/110) surgeons indicated that the way they have managed syndesmotic injuries has changed at some point in their career, while 33% (36/110) specified that they could foresee themselves changing their management of these injuries in the future.Conclusions: There was significant variability among responders in preoperative and intraoperative assessment technique, fixation construct, screw removal protocol, and postoperative weightbearing protocol. This study raises awareness of differences in and factors predictive of management strategies and should be used for further discussion when determining a potential gold standard for the management of these complex injuries.

Management of Ankle Fractures with Syndesmotic Disruption: A Survey of Orthopaedic Surgeons

Category:Ankle; TraumaIntroduction/Purpose:With an increasing frequency of syndesmotic fixation during ankle fracture ORIF and no current gold standard management protocol, it is important for surgeons to understand the frequency and usage patterns of the various techniques among other orthopaedic surgeons. The purposes of this study are to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption and to identify surgeon demographics predictive of syndesmotic management.Methods:An 18-question survey, including 10 specific syndesmotic management questions was sent to the Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA), as well as sent to email addresses of foot and ankle-fellowship trained surgeons. Surgeon demographic questions included years, country, and type of practice, fellowship(s) completed, setting of ankle fracture surgery, and number of ankle fractures operated on per year. Multinomial regression analysis was performed to determine if surgeon demographics were predictive of syndesmotic management.Results:One-hundred ten orthopaedic surgeons completed our survey. Selected predictors of syndesmotic management included: private practice with academic appointments (0.077 [0.007, 0.834]; p=0.035) being predictive of not using screws through an ORIF plate; foot & ankle fellowship (9.981 [1.787, 55.764]; p=0.009) and trauma fellowship (6.644 [1.302, 33.916]; p=0.023) predictive of utilizing screws through a plate; no fellowship (14.886 [1.226, 180.695]; p=0.034) predictive of only using 1 screw; and surgeons practicing in the U.S. were more likely to not use screws across just 3 cortices (0.031 [0.810, 3.660]; p=0.009). Additionally, among those utilizing suture-button devices, foot & ankle fellowship-trained surgeons were more likely to implement suture-button through plate (7.676 [1.286, 45.806]; p=0.025).Conclusion:Several surgeon factors influence decision making in the management of ankle fractures with syndesmotic disruption. This study raises awareness of differences in management strategies that should be used for further discussion when determining a potential gold standard for management of these complex injuries.

Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons

BackgroundManagement of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability. MethodsAn online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice. ResultsA total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss. ConclusionsConsistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.

(FLiP) fracture-table vs. lateral positioning for femoral intramedullary nailing: A survey of orthopaedic surgeon preferences

BackgroundFemoral shaft fractures are common and severe injuries that often occur alongside other complex, high-energy injuries. Definitive internal fixation using reamed, locked intramedullary nailing (IMN) has become the standard of care in adequately resuscitated patients, commonly performed in the supine position with utilization of a fracture table. The lateral position, without the use of traction, offers an alternative that may be associated with lower complication rates. Given the lack of high-quality evidence in the area, this study was designed to assess the attitudes, knowledge base and preferences of Orthopaedic surgeons regarding patient positioning during antegrade IMN of femoral shaft fractures. MethodsOrthopedic surgeon members of the AO North America, Canadian Orthopaedic Association and the Ontario Orthopaedic Association were invited to participate in a web-based survey addressing the management of femoral shaft fractures and the need for further research in this area. ResultsMost surgeons (56%) favored treating mid-shaft femur fractures in the supine position using a fracture table compared to supine/sloppy lateral (29%) or direct lateral (12%) with the leg free draped. Canadian surgeons showed a significantly higher preference for supine positioning with a fracture table when compared to their American colleagues. Academic and higher-level trauma center surgeons were more likely to prefer the sloppy lateral or direct lateral positioning with manual traction compared to community surgeons. The most commonly cited perceived barrier for utilizing the lateral position was expertise and lack of available assistants. Forty-five percent of respondents expressed interest in being involved in a randomized control trial comparing lateral positioning vs. supine with traction. ConclusionConsensus surrounding the positioning and utilization of traction in femoral shaft fractures is lacking. Given the perceived possible benefits and reduced complications using the lateral position and free-leg draping, further research is warranted to determine the optimal positioning for these injuries during femoral IMN. Level of EvidenceIV Study TypeCross-sectional Survey

Dissecting disparity: improvements towards gender parity in leadership and on the podium within the Canadian Orthopaedic Association

ObjectivesThe purpose of this paper was to analyse the 15-year trend of women in leadership roles within the Canadian Orthopaedic Association (COA). This included not only leadership positions at the committee level in the association but also the more visible podium positions in the annual meeting programme: research podium and poster presentations, session moderators, panellists and faculty.MethodsData on the numbers of male and female members were gathered from COA membership records for the most recent 5 years (2014–2018), as well as for 10 years previous (2009) and 15 years previous (2004). Male and female representation on COA committees, as well as the number of presenters at the annual meeting was calculated. Descriptive data were generated to compare the changes in gender representation over time.ResultsIn Canada, in 2018, 11.2% of orthopaedic surgeons were female. Within the COA, 17.6% of the members are female, with active female surgeons comprising 11.6% of the total membership. The largest increase in representation of women within the COA is in the trainee category which is 25.3% female. At the 2018 annual meeting, 25% of the attendees were women, with 22% of all podium appearances by women. Not including research presentations, women participated as faculty in 11% of the appearances at the 2018 annual meeting.ConclusionIn conclusion, gender parity is not yet a reality in Canadian orthopaedics; however, the number of females in leadership roles and on the podium is consistent with the current gender diversity within the COA membership. Further efforts will be required to improve gender diversity as well as to encourage female medical students to consider orthopaedics as a specialty. The availability of female role models that are visible on the podium and in leadership positions may be one strategy to encourage the journey toward gender parity.

An international, cross-sectional survey of the management of Vancouver type B1 periprosthetic femoral fractures around total hip arthroplasties

IntroductionThe incidence of periprosthetic femoral fractures around total hip arthroplasties is increasing. Fractures around a stable implant stem (Vancouver type B1) are among the most common of these fractures. Various fixation strategies for Vancouver type B1 periprosthetic fractures have been reported in the literature; however, little high-level evidence exists. This study was designed to determine the current management strategies and opinions among orthopaedic surgeons treating Vancouver type B1 periprosthetic femoral fractures, and to evaluate the need for a large prospective randomized controlled trial for the management of these injuries. MethodsOrthopaedic surgeon members of the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the Hip Society were invited to participate in a 51-item web-based survey surrounding the management of periprosthetic femoral fractures around total hip replacements, as well as the perceived need for future research in this area. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training. ResultsFor Vancouver type B1 fractures, open reduction and internal fixation (ORIF) with locked plating was favoured slightly over ORIF with cable plating ± cortical strut allograft (51.1% versus 45.5%). When compared to cable plating with cortical strut allograft, respondents believed that isolated locked plating resulted in lower nonunion and reoperation rates, but similar infection and malunion rates. Subgroup analyses revealed that practice type, surgeon age, case volume, and fellowship training influenced surgeons’ management of periprosthetic femoral fractures and beliefs regarding complications. There is high demand for a large prospective randomized controlled trial for Vancouver type B1 fracture fixation. ConclusionsConsensus surrounding the management of Vancouver type B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries.

Atypical femur fractures: a survey of current practices in orthopedic surgery.

We aimed to determine current AFF treatment practices of orthopedic surgeons to inform clinical practice guideline development. A self-administered online survey was developed and sequentially posted on the Orthopaedic Trauma Association (OTA) website from July to August 2015 and the Canadian Orthopaedic Association (COA) website from December 2015 to January 2016. Level of confidence in diagnosis and treatment as well as treatment preferences between respondents who self-identified as trauma surgeons vs. non-trauma surgeons were compared. A total of 172 completed surveys were obtained (OTA, N=100, 58%; COA, N=72, 8%). Seventy-eight percent of respondents had treated ≥1 AFF in the previous 6months. Seventy-six percent reported feeling extremely or very confident in diagnosing AFF (trauma 84% vs. non-trauma surgeons 70%, p=0.04), and 63% reported feeling extremely or very confident in treating AFF (trauma 82%, non-trauma surgeons 50%, p<0.01). Preferred management for complete and symptomatic incomplete AFFs was surgical fixation with a cephalomedullary nail (CMN) by 88 and 79%, respectively, while close follow-up was preferred for asymptomatic incomplete AFFs in 72% of respondents. Trauma surgeons used the CMN more frequently than non-trauma surgeons (90 vs. 76% p=0.03). In patients with bilateral AFFs, with one side surgically treated, 56% were extremely likely to surgically treat the contralateral side, if symptomatic. Most felt guidelines (81%) and educational resources (73%) would be valuable. Current orthopedic treatment practices for AFFs are variable. The results of this survey will inform the development of practice guidelines and educational resources.

An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice.

ObjectivesEvidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making.Materials and MethodsA 29-question electronic survey was distributed to the readership of an established orthopaedic journal with international readership. The survey aimed to analyse the influence of both extrinsic (journal quality, investigator profiles, etc.) and intrinsic characteristics (study design, sample size, etc.) of research studies in relation to their influence on practice patterns.ResultsA total of 353 surgeons completed the survey. Surgeons achieved consensus on the ‘importance’ of three key designs on their practices: randomised controlled trials (94%), meta-analyses (75%) and systematic reviews (66%). The vast majority of respondents support the use of current evidence over historical clinical training; however subjective factors such as journal reputation (72%) and investigator profile (68%) continue to influence clinical decision-making strongly.ConclusionAlthough intrinsic factors such as study design and sample size have some influence on clinical decision-making, surgeon respondents are equally influenced by extrinsic factors such as investigator reputation and perceived journal quality.Cite this article: Dr M. Ghert. An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice. Bone Joint Res 2016;5:130–136. DOI: 10.1302/2046-3758.54.2000578.

Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons.

When fracture management includes operative fixation with a load-sharing construct in good-quality bone, screening for healing problems or hardware failure with radiographs in the first 6 postoperative weeks may be unnecessary. I sought to determine Canadian orthopedic surgeons' current protocol for early postoperative radiographs of stable, internally fixed fractures as well as their willingness to adopt a simplified protocol. Members of the Canadian Orthopaedic Association were surveyed electronically. Five examples of surgically treated fractures were chosen to represent the spectrum of load-sharing constructs. The survey collected demographic data and inquired about current postoperative radiograph protocols and consideration of a simplified protocol. Of the 822 emailed invitations to complete the survey, 400 were opened and 243 surveys were completed. Most participants (91%) practised in Canada and managed some trauma (91%), but were not trauma specialists (82%). Surgeon experience was equally distributed. Sixty-six percent of respondents acquire immediate postoperative radiographs after femur and tibia intramedullary nails, and 62% repeat radiographs at 2-week follow-up. Fifty-one percent of respondents acquire immediate postoperative radiographs after forearm, humerus and ankle internal fixation, and 69% repeat radiographs at 2-week follow-up. Of the respondents who currently acquire radiographs, 33% would consider foregoing immediate postoperative radiographs after intramedullary nailing of femur and tibia fractures, while 25% would forego them at 2-week follow-up. Similarly, 58% would consider foregoing radiographs immediately after internal fixation of forearm, humerus and ankle fractures, while 24% would forego them at 2-week follow-up. Many Canadian orthopedic surgeons do not acquire screening postoperative radiographs after stable fracture fixation, and many more are willing to adopt this practice. These findings support investigating the safety and cost-effectiveness of a simplified postoperative radiographic protocol.

Comparing Entry Points for Antegrade Nailing of Femoral Shaft Fractures.

The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review was to determine whether there is a difference in operative parameters, healing, and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3 major orthopedic meetings (American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) was conducted. Four studies (570 patients) met the inclusion criteria. Mean patient age was 34.5 years, and 60.4% were male. The GT entry point was associated with significantly shorter operative (mean difference [MD], -20.05 minutes [95% confidence interval (CI), -23.09 to -17.02]; P<.00001) and fluoroscopy times (MD, -24.55 seconds [95% CI, -43.23 to -5.86]; P=.01). There was no significant difference in nonunion (risk ratio [RR], 0.74 [95% CI, 0.35 to 1.58]; P=.44) and delayed union rates (RR, 0.94 [95% CI, 0.41 to 2.14]; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review supports the use of the GT entry point during antegrade nailing of femoral shaft fractures over the PF entry point, with regard to shorter operative and fluoroscopy times. Healing and complication rates were not related to the entry point. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.

Surgeon – Therapist Communication: Do All Members See Eye-to-Eye?

Background. Poor interprofessional collaboration has been shown to negatively affect patient care within many fields of medicine. Growing evidence is suggesting that improved interprofessional collaboration can positively affect patient care. Postoperative rehabilitation of many orthopedic conditions necessitates the combined efforts of surgeons, and therapists. There is a paucity of literature examining collaboration among orthopedic surgeons and therapists regarding postoperative rehabilitation. Objectives. The following study examines the perceived quality of communications between orthopedic surgeons and therapists employing an online survey. We hypothesized that collaborative practice patterns result in improved perceptions of communication. Methods. Ethics board approval was obtained. Subjects consisted of orthopedic surgeons, licensed physiotherapists and certified athletic therapists. The online survey was distributed through the Canadian Orthopaedic Association (COA), the Canadian Physiotherapy Association (CPA) and the Canadian Athletic Therapists Association (CATA). Data analysis was performed using Stata/IC 12.1 (Stata Corp, College Station, TX, USA). Descriptive statistics were calculated to determine the median responses and ranges. Median responses were compared using the Kruskal–Wallis one-way analysis of variance. Qualitative analysis regarding text responses was performed by three reviewers. Results. Reponses were received from all specialties (COA 164, CPA 524, CATA 163). There were significant differences in the perceived quality of communication by quantitative and qualitative analysis (p < 0.001). Analysis of communication within practice patterns of stand-alone versus collaborative revealed improved perception of communication quality with increased contact. 65.6% of responders that practiced as stand-alone had a negative view of interprofessional communication. 48.4% of responders in a collaborative practice had a positive view of interprofessional communication. Analysis of the preferred form of communication found that orthopedic surgeons felt the most useful referral information was a pre-printed consult sheet (odds ratio [OR] = 1.56, p < 0.001), whereas therapists were more likely to rank consult notes (OR = 1.27, p < 0.042) and operative reports (OR = 1.20, p < 0.092) as a more useful form of communication. Conclusions. Collaborative practice shows improved perceptions of communication between specialties. Orthopedic surgeons perceive a higher quality of communication than therapists. Therapists and orthopedic surgeons also do not agree on the information that should be relayed between the specialties regarding postoperative rehabilitation.

CHAracteristics of research studies that iNfluence practice: a GEneral survey of Canadian orthopaedic Surgeons (CHANGES): a pilot survey.

BackgroundEvidence Based Medicine (EBM) is increasingly being applied to inform clinical decision-making in orthopaedic surgery. Despite the promotion of EBM in Orthopaedic Surgery, the adoption of results from high quality clinical research seems highly unpredictable and does not appear to be driven strictly by randomized trial data. The objective of this study was to pilot a survey to determine if we could identify surgeon opinions on the characteristics of research studies that are perceived as being most likely to influence clinical decision-making among orthopaedic surgeons in Canada.MethodsA 28-question electronic survey was distributed to active members of the Canadian Orthopaedic Association (COA) over a period of 11 weeks. The questionnaire sought to analyze the influence of both extrinsic and intrinsic characteristics of research studies and their potential to influence practice patterns. Extrinsic factors included the perceived journal quality and investigator profiles, economic impact, peer/patient/industry influence and individual surgeon residency/fellowship training experiences. Intrinsic factors included study design, sample size, and outcomes reported. Descriptive statistics are provided.ResultsOf the 109 members of the COA who opened the survey, 95 (87%) completed the survey in its entirety. The overall response rate was 11% (95/841). Surgeons achieved consensus on the influence of three key designs on their practices: 1) randomized controlled trials 94 (99%), 2) meta-analysis 83 (87%), and 3) systematic reviews 81 (85%). Sixty-seven percent of surgeons agreed that studies with sample sizes of 101–500 or more were more likely to influence clinical practice than smaller studies (n = <100). Factors other than design influencing adoption included 1) reputation of the investigators (99%) and 2) perceived quality of the journal (75%).ConclusionAlthough study design and sample size (i.e. minimum of 100 patients) have some influence on clinical decision making, surgeon respondents are equally influenced by investigator reputation and perceived journal quality. At present, continued emphasis on the generation of large, methodologically sound clinical trials remains paramount to translating research findings to clinical practice changes. Specific to this pilot survey, strategies to solicit more widespread responses will be pursued.

Management of young femoral neck fractures: Is there a consensus?

BackgroundFemoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures. MethodsA 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course. Results540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1–5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h. ConclusionsMultiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes.

The 2013 American-British-Canadian Traveling Fellowship: innovation, accountability, and insight.

The American-British-Canadian (ABC) Exchange Fellowship was conceived by Dr. Robert I. Harris of the University of Toronto. In 1947, Dr. Harris, President of the American Orthopaedic Association (AOA), was concerned that “because of World War II and the accompanying post-war difficulties, young orthopaedic surgeons of Great Britain would find it difficult, if not impossible, to visit orthopaedic centres in the United States and Canada.”1 With the partnership of the Presidents of the Canadian Orthopaedic Association (COA, Edouard Samson) and the British Orthopaedic Association (BOA, S.A.S. Malkin), Dr. Harris designed a tour of North America and attracted funds. In the spring of 1948, thirteen orthopaedic surgeons from Great Britain sailed to North America on the RMS Queen Elizabeth and toured as the first ABC fellows. The following year, a reciprocal tour with fifteen North American orthopaedic surgeons took place in the United Kingdom. During the ensuing four years, debate raged within the orthopaedic associations regarding the future of the ABC Exchange Fellowship. While detractors were a vocal minority, the prevailing force was the persistence of individuals such as British fellows Philip Newman, Derick Strange, Sir Reginald Watson-Jones (President of the BOA), and Sir Henry Osmond-Clarke, who collectively extolled the significance of a face-to-face academic and cultural exchange. The ABC Exchange Fellowship resumed in 1954 with British fellows traveling to North America. The legacy of the ABC tour has continued without interruption since that time. The Fellowship was further acclaimed in 1958 when the fellows were received at the White House by President Dwight D. Eisenhower, who emphasized the value and importance of face-to-face exchanges. In 1964, the Ruth B. Lilly Fellowship Fund was created and ensured the continuation of the Fellowship in perpetuity. South Africa joined the tour in 1983, followed by Australia and New Zealand in 1985. During the …