Search

Introduction: Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis. Objective: A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care. Methods: A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today. Conclusion: Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided. [ABSTRACT FROM AUTHOR]

Purpose : Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation. Methods: A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained. Results: Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia. Conclusion: This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients. [ABSTRACT FROM AUTHOR]

Summary: In this qualitative secondary analysis, patients with a fragility fracture described needing informal care post-fracture. A significant proportion reported receiving no care or not enough care, often devising strategies to care for themselves. Requesting help from multiple individuals allowed patients to minimize the burden to family and friends. Introduction: In individuals with fragility fractures, our objectives were to examine (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health. Methods: A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45 years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving "enough care", "insufficient care", or "no care". Results: Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture. Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants' fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health. Conclusion: Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients' lives and potentially support the care needs of patients as part of their services. [ABSTRACT FROM AUTHOR]

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult. [ABSTRACT FROM AUTHOR]

Purpose: Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes.Methods: We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis.Results: Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed.Conclusions: Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol. [ABSTRACT FROM AUTHOR]

To examine messages perceived by members of an osteoporosis (OP) patient group from various healthcare providers regarding bone health. We conducted a phenomenological (qualitative) study in members of an OP patient group who resided in Canada, had sustained a fragility fracture at 50+ years old, and were not taking antiresorptive medication at the time of that fracture. Participants were interviewed for approximately 1 h by telephone and responded to questions about visits to healthcare providers for their bone health and what was discussed during those visits. We analyzed the data guided by Giorgi's methodology. We interviewed 28 members (2 males, 26 females; 78 % response rate), aged 51-89 years old. Most participants perceived that their specialist was more interested than their primary care physician in bone health and took the time to discuss issues with them. Participants perceived very few messages from the fracture clinic and other providers. We found many instances where perceived messages within and across various healthcare providers were inconsistent, suggesting there is a need to raise awareness of bone health management guidelines to providers who treat fracture patients. [ABSTRACT FROM AUTHOR]

Objective: A secondary analysis of a systematic review on interventions to improve osteoporosis (OP) investigation and treatment was conducted to examine reported key outcomes: (1) the cost of the intervention; (2) the proportion of patients taking OP medication beyond 6 months of the intervention; and (3) the proportion of patients who re-fractured. Methods: Fifty-seven articles reporting on 54 studies (64 interventions) from 11 countries were included. Intervention studies to improve OP management were eligible if they were conducted in an orthopedic setting and included primary data on ≥20 patients presenting with a hip fracture or any fragility fracture. To compare outcome data across all interventions regardless of study design, an equated proportion (EP) using a denominator based on the intention-to-treat principle was derived. Whether a cost analysis had been conducted, the EP of patients who were taking medication beyond 6 months of the intervention, and the EP of patients who re-fractured during the study period were documented. Results: Of the 54 studies, 2 reported a cost analysis and demonstrated that the interventions were at least cost-effective. The EP for medication use beyond 6 months of the intervention ranged from 17 to 56% for four studies. The EP for re-fracture ranged from 0 to 5% for four studies. Conclusion: Most interventions did not report key outcomes. In addition, authors used varying time frames for re-fracture and medication use, making direct comparisons impossible. Authors should consider including intervention costs, medication use beyond 6 months of the intervention, and re-fracture data in future fracture secondary prevention programs. [ABSTRACT FROM AUTHOR]

Objective: To examine experiences and behaviours with bone health management post-fracture among members of a national osteoporosis (OP) patient group. Methods: A qualitative study was conducted in English-speaking members of the group who had sustained a fragility fracture at 50+ years old and were not taking OP pharmacotherapy at the time of that fracture. Participants were recruited through an advertisement in the patient group newsletter and interviewed for ~1 h by telephone, responding to questions regarding visits to health care providers and their behaviours regarding bone health. We analysed the data following Giorgi's methodology. Results: Twenty-eight eligible participants (26 females, two males; 78 % response rate) aged 51-89 years old completed an interview. More than half of our participants described effective consumer behaviours, including making requests of health care providers for referrals to bone specialists, bone mineral density tests, and prescription medication. Conclusion: Members of an OP patient group described effective consumer behaviours that could be incorporated as skill sets in post-fracture interventions to improve bone health. [ABSTRACT FROM AUTHOR]

Longstanding rheumatoid arthritis (RA) leads to disability, caused mainly by joint destruction. The current goals of surgical intervention are to restore function and quality of life, prevent joint deterioration, relieve pain, and correct deformity. A number of different surgical treatment options are available to patients with RA, including synovectomy, arthrodesis, joint replacement, and soft tissue and special hand surgery; nonoperative management is also important. Decision-making and timing for orthopedic intervention are complex issues because of polyarticular involvement. Functional impairment, pain, and the subsequent loss of quality of life and inability to work have become the main considerations for surgical reconstruction. Early referral for orthopedic treatment can lead to improved functional benefit for patients with RA. The decision for orthopedic intervention should be established by an interdisciplinary team that includes rheumatologists and orthopedic surgeons experienced in the surgery of RA. Priority should be given to the joint that causes the greatest disability and pain. Disease progression and pharmaceutical treatment options should be taken into consideration when establishing an orthopedic intervention protocol. [ABSTRACT FROM AUTHOR]

We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture "controls," selected from among fracture clinic attendees in the 6–9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years; 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p<0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results. [ABSTRACT FROM AUTHOR]

This study documents a model of carrageenan-induced chronic inflammatory arthritis in the rat, using quantitative histomorphometric assessment. Ten Sprague-Dawley female rats were randomly assigned to one of two groups. Arthritis was induced in the right tibiofemoral joint by 7 intra-articular injections of 0.02 mL of 1% carrageenan in the arthritic group over 24 days. The control (normal) group was injected with 0.02 mL of saline in the right tibiofemoral joint. Sagittal sections of the right knee joint (distal femur and proximal tibia) were assessed by histomorphometry using the LECO 2001 image analysis system. Articular cartilage thickness, epiphyseal plate thickness, subchondral bone plate thickness, trabecular bone volume and thickness of the synovial lining cell layer were measured. Differences between normal and arthritic groups were statistically significant for articular cartilage thickness of the femur, epiphyseal plate thickness of both the femur and tibia, subchondral bone plate thickness of the tibia and the thickness of the synovial lining cell layer. These findings demonstrate that carrageenan-induced arthritic changes are similar to other, established models of arthritis in the rat. [ABSTRACT FROM AUTHOR]

Originally published as 402, 304?309; 1999Bone remodelling and bone loss are controlled by a balance between the tumour necrosis factor family molecule osteoprotegerin ligand (OPGL) and its decoy receptor osteoprotegerin (OPG). In addition, OPGL regulates lymph node organogenesis, lymphocyte development and interactions between T cells and dendritic cells in the immune system. The OPGL receptor, RANK, is expressed on chondrocytes, osteoclast precursors and mature osteoclasts. OPGL expression in T cells is induced by antigen receptor engagement, which suggests that activated T cells may influence bone metabolism through OPGL and RANK. Here we report that activated T cells can directly trigger osteoclastogenesis through OPGL. Systemic activation of T cells in vivo leads to an OPGL-mediated increase in osteoclastogenesis and bone loss. In a T-cell-dependent model of rat adjuvant arthritis characterized by severe joint inflammation, bone and cartilage destruction and crippling, blocking of OPGL through osteoprotegerin treatment at the onset of disease prevents bone and cartilage destruction but not inflammation. These results show that both systemic and local T-cell activation can lead to OPGL production and subsequent bone loss, and they provide a novel paradigm for T cells as regulators of bone physiology. [ABSTRACT FROM AUTHOR]

A correction to the article "Perceived messages about bone health after a fracture are not consistent across healthcare providers" published in the July 25, 2014 issue of the periodical is presented.