Risk of Recurrent Fracture: A Population-Based Study.

OBJECTIVES: To determine if children who sustain a fracture in childhood had an increased rate of fracture later in childhood or early adulthood. The a priori null hypothesis was that children who sustained a fracture would not have an increased rate of future fractures compared with children who did not sustain a fracture when controlling for important covariates. METHODS: This is a population-based retrospective cohort study using health care databases in Ontario. Approximately 2.5 million healthy children aged 0 to 15 years living in Ontario, Canada between April 1, 2003, and March 31, 2004, were included and followed for 7 years. The exposure was occurrence of any fracture during a 1-year baseline period. The main outcome was any fractures during a 7-year follow-up period. RESULTS: A total of 43 154 children suffered a fracture during the baseline year (17.5 fractures per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture (incidence rate ratio: 1.60; 95% confidence interval: 1.46-1.75; P < .0001) during the follow-up period after adjustment for sex, rurality, history of previous fracture, and the occurrence of other injuries (head and soft-tissue). CONCLUSIONS: The occurrence of a fracture during childhood was associated with an increased rate of future fractures compared with children who did not suffer a fracture. Attempting to improve childhood bone health by targeting children who present to a fracture clinic with multiple fracture risk factors may be a useful strategy for secondary prevention of fractures and may have beneficial effects on long-term bone health.

Epidemiology of Slipped Capital Femoral Epiphysis in Ontario, Canada.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a well-characterized disorder of the hip seen in adolescent patients. It is characterized by deformity secondary to failure through the proximal femoral growth plate, which results in posterior-inferior displacement of the epiphysis on the proximal femoral metaphysis. Long-term sequelae of SCFE may include osteonecrosis, residual deformity, leg length discrepancy, degenerative joint disease, and chronic pain. The long-term consequences of SCFE may be the source of significant morbidity for the patient, and depending of the local incidence of this condition, may represent a significant expenditure of health care resources. Historically, the true incidence of SCFE within Ontario has been approximated using US-based studies of arguably comparable patient populations. In our study, we aimed to characterize the epidemiology of SCFE in the province of Ontario. METHODS: We used a prospectively collected, not-for-profit Ontario research database to identify recorded cases of SCFE between April 1, 2002 and March 31, 2011. Specifically, we identified all hospital discharges with an ICD-9 or 10 diagnostic codes for SCFE in the Canadian Institute for Health Information Discharge Abstract database. RESULTS: Over the 10-year study period, there were 648 cases of SCFE with an average annual incidence rate of 5.68/100,000 in Ontario. CONCLUSIONS: We have observed a trend toward decreasing incidence rates of SCFE in Ontario over the last 10 years. The determination for the underlying causes for the changing trends of SCFE may be relevant for initiating public health campaigns directed at reducing the incidence of SCFE LEVEL OF EVIDENCE:: Level IV-epidemiological study.

The impact of pedestrian countdown signals on single and two vehicle motor vehicle collisions: a quasi-experimental study.

The objective of this study was to examine the impact of pedestrian countdown signals (PCS) on the rate of motor vehicle collisions (MVCs) in Toronto, Canada. A quasi-experimental design was used to compare rates of single and two vehicle MVCs before and after installation of PCS in Toronto, Canada between January 2005 and December 2009. Collision incidence rates were compared using Poisson regression analyses with adjustment for relevant cofounders and reported as incidence rate ratios (IRR) with 95% confidence intervals (CI). Secondary analyses were performed on subsets of collisions by collision type and injury severity. A total of 94,175 MVCs occurred at or near 1965 intersections at which PCS were installed over the five-year study period. Overall, the MVC incidence rate increased 7.5% (IRR = 1.075; 95% CI: 1.042-1.109; p < 0.0001) after installation of PCS. The installation of PCS led to an increase in MVCs. PCS may have an unintended consequence of increasing the rate of MVCs.

Patient-Reported Health Outcomes After in Situ Percutaneous Fixation for Slipped Capital Femoral Epiphysis: An Average Twenty-Year Follow-up Study.

BACKGROUND: Percutaneous in situ fixation is the gold-standard treatment for stable slipped capital femoral epiphysis (SCFE). While numerous studies have documented good to excellent long-term clinical and radiographic outcomes, few have documented long-term patient-reported outcomes of patients with this condition. METHODS: This retrospective study was performed to document long-term patient-reported outcomes of a cohort of sixty-four patients with SCFE (ninety-one affected hips) and determine whether the slip angle was associated with poorer health outcomes as measured with the Short Form-12 (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, modified Harris hip score (mHHS), and University of California at Los Angeles (UCLA) Activity Scale. RESULTS: The mean age at presentation was 12.6 years, and the mean duration of follow-up was 19.6 years. At the time of follow-up, the cohort reported higher rates of diabetes, obesity, and hypertension than the general U.S. POPULATION: The mean body mass index (BMI) had increased by 10.2 kg/m(2), with 72% of the subjects meeting the criteria for obesity (BMI > 30 kg/m(2)) at the time of follow-up. The mean age and sex-adjusted PCS and MCS scores were 49.6 and 50.0, respectively, and the mean mHHS was 84.9. Multivariable general linear modeling revealed no association between the initial slip angle and the PCS, MCS, mHHS, or UCLA Activity Scale score. Male sex and a lower BMI were the only predictors of better long-term PCS, mHHS, and UCLA Activity Scale scores. Subjects with a bilateral slip had outcomes similar to those with unilateral disease. CONCLUSIONS: The general self-reported health of this cohort was poor compared with that of the general population. The slip angle on presentation did not correlate with any patient-reported outcome measure collected for this study. Higher BMI was one of the only clinical predictors of patient-reported outcomes.

Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study.

OBJECTIVE: Therapeutic intraarticular injections are used in the management of hip osteoarthritis (OA). Some studies suggest that their use increases the risk of infection and subsequent revision surgery after primary total hip arthroplasty (THA), while others do not. We undertook this study to clarify the relationship between prior intraarticular injection and the risk of complication in a subsequent primary THA. METHODS: In a cohort of patients with hip OA who underwent a primary elective THA between 2002 and 2009, we identified those who received ≥1 intraarticular injection performed by a radiologist in the 5 years preceding their THA. Multivariable Cox proportional hazards models were used to determine the relationship between receipt of a presurgical injection (no injection, 1-5 years prior to THA, or <1 year prior to THA) and the occurrence of postsurgical joint infection and revision THA in the following 2 years, while controlling for confounders. RESULTS: Of 37,881 eligible THA recipients, 2,468 (6.5%) received an intraarticular injection performed by a radiologist within 5 years of their THA (1,691 at <1 year, 777 at 1-5 years). Controlling for age, sex, comorbidity, frailty, income, and provider volume, those who had an injection in the year preceding surgery were at increased risk of infection (adjusted hazard ratio [HR] 1.37, P = 0.03) and revision THA (adjusted HR 1.53, P = 0.03) within 2 years of the primary THA, relative to patients who did not. The association between prior injection and revision arthroplasty was attenuated and became nonsignificant (adjusted HR 1.41, P = 0.13) after occurrence of postoperative infection was controlled for in the regression model. No effect was found for injection 1-5 years prior to surgery. CONCLUSION: Intraarticular injection in the year preceding THA independently predicted increased risk of infection leading to early revision surgery. Further studies are warranted to elucidate explanations for these findings.

EOS low-dose radiography: a reliable and accurate upright assessment of lower-limb lengths.

BACKGROUND: Children with lower-limb-length discrepancy require repeated radiographic assessment for monitoring and as a guide for management. The need for accurate assessment of length and alignment is balanced by the need to minimize radiation exposure. We compared the accuracy, reliability, and radiation dose of EOS, a novel low-dose upright biplanar radiographic imaging system, at two different settings, with that of conventional radiographs (teleoroentgenograms) and computed tomography (CT) scanograms, for the assessment of limb length. METHODS: A phantom limb in a standardized position was assessed ten times with each of four different imaging modalities (conventional radiographs, CT scanograms, EOS-Slow, EOS-Fast). A radiation dosimeter was placed on the phantom limb, on a portion closest to the radiation source for each modality, in order to measure skin-entrance radiation dose. Standardized measurements of bone lengths were made on each image by consultant orthopaedic surgeons and residents and then were assessed for accuracy and reliability. RESULTS: The mean absolute difference from the true length of the femur was significantly lower (most accurate) for the EOS-Slow (2.6 mm; 0.5%) and EOS-Fast (3.6 mm; 0.8%) protocols as compared with CT scanograms (6.3 mm; 1.3%) (p < 0.0001), and conventional radiographs (42.2 mm; 8.8%) (p < 0.0001). There was no significant difference in accuracy between the EOS-Slow and EOS-Fast protocols (p = 0.48). The mean radiation dose was significantly lower for the EOS-Fast protocol (0.68 mrad; 95% confidence interval [CI], 0.60 to 0.75 mrad) compared with the EOS-Slow protocol (13.52 mrad; 95% CI, 13.45 to 13.60 mrad) (p < 0.0001), CT scanograms (3.74 mrad; 95% CI, 3.67 to 3.82 mrad) (p < 0.0001), and conventional radiographs (29.01 mrad; 95% CI, 28.94 to 29.09 mrad) (p < 0.0001). Intraclass correlation coefficients showed excellent (>0.90) agreement for conventional radiographs, the EOS-Slow protocol, and the EOS-Fast protocol. CONCLUSIONS: Upright EOS protocols that utilize a faster speed and lower current are more accurate than CT scanograms and conventional radiographs for the assessment of length and also are associated with a significantly lower radiation exposure. In addition, the ability of this technology to obtain images while subjects are standing upright makes this the ideal modality with which to assess limb alignment in the weight-bearing position. This method has the potential to become the new standard for repeated assessment of lower-limb lengths and alignment in growing children. CLINICAL RELEVANCE: This study assesses the reliability and accuracy of a diagnostic test used for clinical decision-making.

Authorship proliferation in the orthopaedic literature.

BACKGROUND: Authorship is the currency of the academic orthopaedic surgeon. There has been an unprecedented increase in the number of authors per publication in many biomedical fields. Possible reasons for this trend include increased complexity of research, "undeserved" authorship, and the "pressure to publish." We explored the change in authorship in two leading orthopaedic journals over a period of sixty years. METHODS: We examined all original research articles and case reports published in The Journal of Bone and Joint Surgery (American and British Volumes) (JBJS-A and JBJS-B) in ten-year intervals from 1949 to 2009. For each article, we determined the number of authors, the geographic origin of the research, and the academic degrees of the authors; we also examined the changes that occurred in these categories. RESULTS: The mean number of authors per original research article increased from 1.6 in 1949 to 5.1 in 2009. There has been a noticeable internationalization of the two journals, with a decreasing proportion of articles from North America and the United Kingdom and Ireland as a result of increased contributions from Europe and the Far East. Authors with advanced research degrees (PhD; MS; MD, PhD; and MD, MS) account for an increasing proportion of contributing authors; over 30% of authors had an advanced research degree in 2009. CONCLUSIONS: Our findings suggest that the trend of authorship proliferation in biomedical research is also seen in the orthopaedic literature. The mean number of authors, the proportion of authors per research article with an advanced research degree, and variation in the geographic origin of articles has increased over the past sixty years.

Hand appearance as a patient motivation for surgery and a determinant of satisfaction with metacarpophalangeal joint arthroplasty for rheumatoid arthritis.

PURPOSE: To determine patient motivations for surgery and satisfaction with outcomes for metacarpophalangeal (MCP) joint arthroplasty in 3 domains (appearance, function, and pain) and whether patient-reported satisfaction correlates with standard outcome measures. METHODS: In a randomized controlled trial of MCP joint implants, 33 patients with rheumatoid arthritis had primary MCP joint arthroplasty: 15 hands received Swanson implants, and 18 received NeuFlex implants. Range of motion, ulnar drift, grip strength, Sollerman hand function test, and the Michigan Hand Questionnaire were collected before surgery and 1 year after surgery. Preoperative patient motivations for and expectations of MCP joint arthroplasty were assessed for function, pain, and appearance. Patient-perceived improvement and satisfaction within the 3 domains and global satisfaction were assessed after surgery. RESULTS: Function was rated the most important motivator for surgery by 31 patients, pain by 22, and appearance by 15. Twenty-six patients rated 2 or more motivators equally high. Michigan Hand Questionnaire subscores were moderately correlated or weakly correlated with patient-reported satisfaction. The Sollerman score was weakly correlated with patient-reported satisfaction. Range of motion, ulnar drift, and grip strength were not correlated with patient-reported satisfaction. More patients stated that a much better improvement was obtained for appearance than for function or pain relief. CONCLUSIONS: Patient expectations of MCP joint arthroplasty were uniformly high. The greatest motivation for surgery was functional improvement. Pain was highly ranked, and 25 patients rated hand appearance as the first or second motivator. Patient satisfaction correlated poorly with traditional outcome measures and moderately with patient-reported outcomes. We conclude that appearance should be considered an important motivator for surgery and determinant of satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

NeuFlex and Swanson metacarpophalangeal implants for rheumatoid arthritis: prospective randomized, controlled clinical trial.

PURPOSE: To compare postoperative range of motion (ROM) and function in a randomized prospective trial of Swanson and NeuFlex metacarpophalangeal (MCP) joint implants. METHODS: A total of 33 patients who had rheumatoid arthritis underwent primary MCP arthroplasty of all 4 fingers in 40 hands; 20 received Swanson implants and 20 received NeuFlex implants. Exclusion criteria included diagnosis of other connective tissue disorders and previous MCP joint surgery. All participants followed the same postoperative rehabilitation protocol. The primary outcome measure was active MCP flexion. Secondary outcomes included active MCP extension, arc of motion, ulnar drift, function (Jamar grip strength and Sollerman hand function test), and the Michigan Hand Questionnaire. Patients were assessed preoperatively and 12 months postoperatively. RESULTS: Patients' mean age was 62.5 years (Swanson) and 58.1 years (NeuFlex) (p = .03). A total of 19 of 20 hands (Swanson) and 14 of 20 hands (NeuFlex) were from female patients. Preoperative active ROM was not significantly different. At follow-up, both groups demonstrated increased active extension and arc of motion (p < .001), reduced active flexion and improved ulnar deviation (p < .001), increased mean Sollerman and Michigan Hand Questionnaire domain scores (p < .001), and improved grip strength (p = .03). Active MCP flexion was significantly greater in all 4 digits of hands with NeuFlex implants compared with Swanson implants. The NeuFlex group demonstrated a greater total arc of motion in the little finger. Implant groups were not significantly different by individual digit for active MCP extension, ulnar drift, and composite flexion. Functional outcomes did not differ between groups. Patients with Swanson implants reported higher Michigan Hand Questionnaire scores in the function and aesthetics domains. CONCLUSIONS: Both implant groups obtained satisfactory clinical improvement after MCP reconstruction of the hand. The NeuFlex group demonstrated superior ROM, whereas the Swanson group had better self-reported function and aesthetics, but not objectively measured function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

The osteoporosis needs of patients with wrist fracture.

OBJECTIVES: To provide information for practitioners regarding the osteoporosis (OP)-related needs of patients who present with low-trauma wrist fractures and are at high risk of subsequent hip fracture. DESIGN: Prospective protocol, retrospective analysis. SETTING: Large urban teaching hospital, regional trauma center. PATIENTS: All outpatients (women > or =40 years; men > or =50 years) who sustained fragility fractures of the wrist between December 1, 2002 and June 30, 2005. INTERVENTION: Patients were evaluated by a coordinator and recruited to an OP program for education, diagnosis, and treatment. Patient demographic data were collected. A baseline questionnaire included fracture and OP risk history, sociodemographics, Osteoporosis Health Beliefs Scale, and Osteoporosis Self-Efficacy Scale. MAIN OUTCOME MEASURES: Fracture history, OP risk factors, attitudes, and beliefs. RESULTS: Of 339 patients with wrist fractures, 286 had fragility fractures (mean age 64.8 years; 82% female) and met the age criteria. Seventeen percent of men and 36% of women with fragility wrist fractures had been previously diagnosed with OP or osteopenia; nearly all of them had been prescribed supplements, and two thirds had received aminobisphosphonate treatment for OP. Half of the patients had one or more risk factors for OP. Most patients were aware of OP, but few felt their fracture could result from OP. Bone densitometry completed on 55 patients in the first year indicated OP or osteopenia in 43 of 55 patients. Patients' health beliefs underestimated the seriousness of OP. Every patient with a fragility fracture of the wrist should understand that: (1) their fracture may be related to OP; (2) by having a fragility fracture, they are at higher risk for hip fracture; and (3) preventive treatment is effective and safe. Information should be partly gender specific. Patients who believe that weak bones didn't cause their fracture require additional attention to motivate them to undergo special treatment. CONCLUSIONS: Intervention by the orthopaedic team to address potential underlying OP in patients with low-trauma wrist fractures should include directed patient education, testing, treatment with supplements and pharmacotherapy where indicated, and referral as needed.

Insufficient flexion of the metacarpophalangeal joint of the little finger following Swanson silicone arthroplasty for rheumatoid arthritis.

Twenty-one patients with rheumatoid arthritis who underwent Swanson metacarpophalangeal (MP) arthroplasty from 1994 to 1999 were assessed for active flexion of individual MP joints an average of 59 months (range 27-114 months) postoperative. Published articles of Swanson MP arthroplasty were reviewed. Experienced hand surgeons were surveyed regarding outcomes of metacarpophalangeal arthroplasty. The MP joint of the little finger displayed significantly less flexion than that of the middle and index finger. Seven of eight published studies which present active MP flexion by individual digit demonstrated less flexion in the little finger compared to the index, middle, and ring finger. Half of surgeons surveyed reported that MP range of motion is shifted toward a more extended position, that MP flexion is limited in the ulnar digits, and that an implant that encourages MP flexion would be helpful. Our experience with this cohort, a review of published literature, and a survey of international experts suggest that Swanson arthroplasty frequently results in a range of flexion of the MP joint of the little finger that may be insufficient for its principal functions.