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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.

Background Operative management for end-stage knee osteoarthritis (OA) primarily consists of arthroplasty. Total knee arthroplasty (TKA) is the so-called gold standard for multicompartmental OA. In selected patients, specifically those with unicompartmental OA and no definite contraindications, realignment osteotomies and unicompartmental knee arthroplasty (UKA) are viable options. UKA offers several advantages over TKA, including preservation of both cruciate ligaments, faster recovery, and less osseous resection. The purpose of this study was to determine the survivorship of UKAs and risk factors for all-cause revision surgery in patients with a minimum follow-up of 10 years in a large population-based database. Methods We performed a population-based cohort study using linked administrative databases in Ontario, Canada. We identified all UKAs performed from January 2002 through December 2006. All patients had a minimum 10-year follow-up. Demographic data and outcomes were summarized using descriptive statistics. We used a Cox proportional hazards model with the Fine and Gray method accounting for competing risks such as death to analyze the effect of surgical and patient factors on the risk of revision of UKA. Results A total of 4,385 patients were identified as having undergone primary UKA from 2002 through 2006 in Ontario. Of these patients, 779 underwent revision surgery, for a cumulative risk for all-cause revision of 16.5% at 10 years (95% confidence interval [CI]: 15.4% to 17.7%). Mechanical loosening was the reason for 83.4% of all revisions. Male sex, diabetes, an age younger than 50 years, and cementless implants were significant risk factors for revision surgery. Residence in a rural or urban setting, income quintile, discharge destination, and type of OA were not associated with the risk of revision. Survivorship at 1, 5, 10, and 15 years was 97.2%, 90.5%, 83.5%, and 81.9%, respectively. Conclusions This study demonstrated a >80% long-term survivorship for UKA based on a large administrative database sample and identified important risk factors for failure including male sex, younger age, diabetes, and cementless fixation. This study found rates of survivorship similar to those previously reported in the literature, while identifying key risk factors for failure. Patient selection has always been identified as a key factor in ensuring successful UKA, and the risk factors identified in this study may help guide decision-making for surgeons and patients dealing with unicompartmental knee OA. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Robust prediction of survival can facilitate clinical decision-making and patient counselling. Non-Caucasian males are underrepresented in most prostate cancer databases. We evaluated the variation in performance of a machine learning (ML) algorithm trained to predict survival after radical prostatectomy in race subgroups. Methods We used the National Cancer Database (NCDB) to identify patients undergoing radical prostatectomy between 2004 and 2016. We grouped patients by race into Caucasian, African-American, or non-Caucasian, non-African-American (NCNAA) subgroups. We trained an Extreme Gradient Boosting (XGBoost) classifier to predict 5-year survival in different training samples: naturally race-imbalanced, race-specific, and synthetically race-balanced. We evaluated performance in the test sets. Results A total of 68,630 patients met inclusion criteria. Of these, 57,635 (84%) were Caucasian, 8173 (12%) were African-American, and 2822 (4%) were NCNAA. For the classifier trained in the naturally race-imbalanced sample, the F1 scores were 0.514 (95% confidence interval: 0.513-0.511), 0.511 (0.511-0.512), 0.545 (0.541-0.548), and 0.378 (0.378-0.389) in the race-imbalanced, Caucasian, African-American, and NCNAA test samples, respectively. For all race subgroups, the F1 scores of classifiers trained in the race-specific or synthetically race-balanced samples demonstrated similar performance compared to training in the naturally race-imbalanced sample. Conclusions A ML algorithm trained using NCDB data to predict survival after radical prostatectomy demonstrates variation in performance by race, regardless of whether the algorithm is trained in a naturally race-imbalanced, race-specific, or synthetically race-balanced sample. These results emphasize the importance of thoroughly evaluating ML algorithms in race subgroups before clinical deployment to avoid potential disparities in care.

The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12 weeks postoperatively. A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12 weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption. Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6 weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2 weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference. The DAA led to functional improvements at 6 weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12 weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.

Olecranon fractures and osteotomies are treated with either tension-band wiring or plate-screw fixation; however, these methods of fixation have high rates of symptomatic hardware, resulting in revision surgery. We describe the novel use of intramedullary noncannulated long screws to gain rigid internal fixation and allow early range of motion. Our procedure differs from traditional intramedullary olecranon fixation as the longer screws, which can commonly be found on many pelvic fixation sets, allow for endosteal purchase at the isthmus of the ulna, which increases the pull-out strength of the screw. This procedure can be done quickly and requires minimal exposure, which minimises anaesthetic exposure, blood loss, and tourniquet time. The construct is not palpable subcutaneously and therefore is less likely to result in symptomatic hardware and revision surgery. How to cite this article Oitment C, Koziarz A, Bozzo A, et al. Intramedullary Cancellous Screw Fixation of Simple Olecranon Fractures. Strategies Trauma Limb Reconstr 2019;14(3):163–167.

Purpose Liposarcoma (LPS) is a one of the most commonly diagnosed soft tissue sarcomas. Little is known about the epidemiology and prognosis of each subtype. We present an analysis of epidemiology and survival of the subtypes of LPS using a national database. Methods We queried the Survival Epidemiology, and End Results (SEER) and the Canadian Institute for Clinical Evaluative Sciences (ICES) databases for data on 7 types of LPS. Pearson’s chi square was used to determine associations between variables and subtypes. Kaplan-Meier and Cox Regression analyses were performed for two tests: one using SEER data and the other using variables common to both SEER and ICES. Results The well-differentiated subtype was the most common subtype identified. Metastatic disease was associated with decreased survival across all subtypes and age >35 was associated with decreased survival in well-differentiated and myxoid subtypes. Tumor grade was associated with decreased survival in the well-differentiated, myxoid, mixed, and round cell subtypes. In the secondary analysis, age >35 was associated with decreased survival in the myxoid subtype. Conclusions The prognosis of liposarcoma differs greatly by subtype. Clinicians should account for patient factors at the time of diagnosis to best navigate treatment of their patients.

Background Femoral 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. Methods Orthopedic 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. Results Most 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. Conclusion Consensus 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 Evidence IV Study Type Cross-sectional Survey

Purpose Robust prediction of progression on active surveillance (AS) for prostate cancer can allow for risk-adapted protocols. To date, models predicting progression on AS have invariably used traditional statistical approaches. We sought to evaluate whether a machine learning (ML) approach could improve prediction of progression on AS. Patients and Methods We performed a retrospective cohort study of patients diagnosed with very-low or low-risk prostate cancer between 1997 and 2016 and managed with AS at our institution. In the training set, we trained a traditional logistic regression (T-LR) classifier, and alternate ML classifiers (support vector machine, random forest, a fully connected artificial neural network, and ML-LR) to predict grade-progression. We evaluated model performance in the test set. The primary performance metric was the F1 score. Results Our cohort included 790 patients. With a median follow-up of 6.29 years, 234 developed grade-progression. In descending order, the F1 scores were: support vector machine 0.586 (95% CI 0.579 – 0.591), ML-LR 0.522 (95% CI 0.513 – 0.526), artificial neural network 0.392 (95% CI 0.379 – 0.396), random forest 0.376 (95% CI 0.364 – 0.380), and T-LR 0.182 (95% CI 0.151 – 0.185). All alternate ML models had a significantly higher F1 score than the T-LR model (all p Conclusion In our study, ML methods significantly outperformed T-LR in predicting progression on AS for prostate cancer. While our specific models require further validation, we anticipate that a ML approach will help produce robust prediction models that will facilitate individualized risk-stratification in prostate cancer AS.

BACKGROUND Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. RESULTS Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and Constant scores, though not approaching the MCID. At the subtype level, anterosuperior plating ranked highest in DASH and Constant functional scores with mean differences reaching 10-point improvement for Constant scores (95% CI 4.4 to 2.5) and 7.6 point improvement for DASH (95% CI 5.2 to 20). CONCLUSIONS We found that surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. In aggregate, surgical treatment did not increase functional scores by amounts that patients were likely to consider clinically important. Use of specific subtypes of plating (anterior, anterosuperior) resulted in improvements in the Constant score that were slightly above the MCID but did not reach the MCID for the DASH score, suggesting that any outcomes-score benefits favoring surgery were likely to be imperceptible or small. In light of these findings, we believe patients can be informed that surgery for this injury can increase the likelihood of union incrementally (about 10 patients would need to undergo surgery to avoid one nonunion), but they should not expect better function than they would achieve without surgery; most patients can avoid surgery altogether with little absolute risk of nonunion. Patients who opt for surgery must be told that the decision should be weighed against complications and the possibility of undergoing a second procedure for hardware removal. Patients opting not to have surgery for acute midshaft clavicle fractures can be told that nonunion occurs in slightly more than 10% of patients, and that these can be more difficult to manage than acute fractures. LEVEL OF EVIDENCE Level I, therapeutic study.

Rhabdomyosarcoma is the most common soft-tissue sarcoma in children and adolescents and accounts for 3% of all pediatric tumors. Subtypes include alveolar, spindle cell, embryonal, mixed-type, pleomorphic, and rhabdomyosarcoma with ganglionic differentiation. The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was queried for patients diagnosed with any type of rhabdomyosarcoma between 1973 and 2014. Patient demographics, tumor characteristics, and incidence were studied with χ2 analysis. Survival was modeled with Kaplan-Meier survival curves and Cox proportional hazards models were used to assess the effect of age and gender on survival. Pleomorphic subtype had higher grade and larger sized tumors compared to other subtypes (p 0.05). This study highlights key differences in the demographic and survival rates of the different types of rhabdomyosarcoma that can be used for more tailored patient counseling. We also demonstrate that large, population-level databases provide sufficient data that can be used in the analysis of rare tumors. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2226-2230, 2019.

Background Lung cancer is one of the most commonly diagnosed cancers and is the leading cause of cancer-related deaths. Metastatic bone disease occurs in 20% to 40% of patients with lung cancer, and these patients often present with pain or skeletal-related events (SREs) that are associated with decreased survival. Bone-modifying agents such as denosumab or bisphosphonates are routinely used; however, to our knowledge, there has been no quantitative synthesis of randomized controlled trial data to determine the most effective pharmacologic treatment of metastatic bone disease because of lung cancer. Questions/purposes We aimed to perform a network meta-analysis of randomized trials to identify the bone-modifying agent that is associated with the (1) highest overall survival, (2) longest time to SRE, (3) lowest SRE incidence, and (4) greatest likelihood of pain resolution. Methods We conducted our study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol and pre-registered the analysis on PROSPERO (ID: CRD42019124364). We performed a librarian-assisted search of MEDLINE, PubMed, EMBASE, Cochrane Library, and Chinese databases including China National Knowledge Infrastructure and Wanfang Data. We included randomized controlled trials reporting outcomes specifically for patients with lung cancer treated with a bisphosphonate or denosumab. SREs included pathologic fractures, spinal cord compression, hypercalcemia of malignancy, or pain resulting in surgical intervention or radiation therapy. We excluded trials exclusively reporting surrogate outcomes such as changes in bone turnover markers. Screening, data extraction, risk of bias evaluation, and Grading of Recommendations Assessment, Development, and Evaluation evaluations were performed in duplicate. We included 131 randomized controlled trials that evaluated 11,105 patients with skeletal metastases from lung cancer. The network meta-analysis was performed using a frequentist model and the R statistical software. Results are reported as relative risks or mean differences, and the I2 value is reported for heterogeneity. The P-score, a measure of ranking certainty that accounts for standard error, is reported for each outcome. Heterogeneity in the network was considered moderate for overall survival and time to SRE, mild for the incidence of SRE, and low for pain resolution. Results For overall survival, denosumab was ranked above zoledronic acid and estimated to confer a mean of 3.3 months (95% CI 0.3-6.3) of increased overall survival compared with untreated patients (P-score = 89%). For the time to SRE, denosumab was ranked first with a mean of 9.1 additional SRE-free months (95% CI 6.7-11.5) compared with untreated patients (P-score = 99%), while zoledronic acid conferred an additional 4.8 SRE-free months (95% CI 3.6-6.1). Reduction in the incidence of SREs was not different between patients treated with denosumab (relative risk 0.54; 95% CI 0.33-0.87) and those treated with zoledronic acid (relative risk 0.56; 95% CI 0.46-0.67). Patients treated with the combination of ibandronate and systemic therapy were more likely to experience successful pain resolution than untreated patients (relative risk 2.4; 95% CI 1.8-3.2). Conclusion In this comprehensive synthesis of all available randomized controlled trial evidence guiding the pharmacologic treatment of bone metastases from lung cancer, denosumab was ranked above zoledronic acid for overall survival and time to SRE and was not different for reducing the incidence of SRE. Both were superior to no treatment for each of these outcomes. Given this, we encourage physicians to consider the use of denosumab or zoledronic acid in treating this patient population. The combination of ibandronate and systemic therapy was the most effective at reducing pain because of metastases. No cost-effectiveness analysis has yet been performed for denosumab and zoledronic acid on patients with metastatic lung cancer, and this represents an avenue for future research. Level of evidence Level I, therapeutic study.

BACKGROUND Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear. METHODS We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection. RESULTS We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various "late" time thresholds for debridement versus "early" thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n = 18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI = 1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214). CONCLUSIONS High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement. LEVEL OF EVIDENCE Prognostic Level IV. See Instruction for Authors for a complete description of the levels of evidence.

ObjectiveIntra-articular (IA) injections represent a commonly used modality in the treatment of hip osteoarthritis (OA). Commonly used injections include corticosteroids (CCS), hyaluronic acid (HA) and platelet-rich plasma (PRP). A network meta-analysis allows for comparison among more than two treatment arms and uses both direct and indirect comparisons between interventions. The objective of this network meta-analysis is to compare the efficacy of the various IA injectable treatments in treating hip OA at up to 6 months of follow-up.DesignThis is a systematic review and network meta-analysis. Bayesian random-effects model was performed to assess the direct and indirect comparisons of all treatment options.Data sourcesPubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception to October 2019.Eligibility criteria for selected studiesRandomised controlled trials assessing the efficacy of CCS, HA, PRP and placebo in the form of IA saline injection for patients with hip OA.ResultsEleven randomised controlled trials comprising 1353 patients were included. For pain outcomes at both 2–4 and 6 months, no intervention significantly outperformed placebo IA injection. For functional outcomes at both 2–4 and 6 months, no intervention significantly outperformed placebo IA injection. Regarding change from baseline at 2–4 months and 6 months, pooled data demonstrated that all interventions (including placebo), with the exception of HA+PRP, led to a clinically important improvement in both pain, exceeding the minimal clinically important difference.ConclusionEvidence suggests that IA hip saline injections performed as well as all other injectable options in the management of hip pain and functional outcomes.

Background context Spinal sarcomas are a rare, heterogeneous group of mesenchymal tumors. Current literature reporting demographic variables and survival information is limited to small case series, and a single registry with variable treatment modalities and time periods. Purpose We report on population-level data regarding all spinal sarcomas diagnosed over a 23-year period in Ontario, Canada, for the purposes of calculating incidence and prevalence of these tumors. Secondarily, survival is assessed by tumor type as well as adjuvant therapies during this time period. Study design Retrospective Cohort Study Patient sample Population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015. Outcome measures Outcome measures include incidence and prevalence of spinal osteosarcoma, Ewing's sarcoma, and chondrosarcoma of the spine, as well as 2-, 5-, 10- and 15-year survival and prevalence of adjuvant therapies. Methods Utilizing population-based data from the Institute for Clinical Evaluative Sciences (ICES) between 1993 and 2015, ICD codes were searched and available data extracted for the purposes of reporting basic demographic information and calculation of Kaplan Meyer survival curves. Databases include the Ontario Cancer Registry, Discharge Abstract Database, Ontario Health Insurance Plan, National Ambulatory Care Reporting System, Registered Persons DataBase (death) were analyzed. Results One hundred and seven spinal sarcomas were identified, with a mean incidence was 0.38 sarcomas per million population per year, that was stable over time. The mean prevalence was 8.1 sarcomas per million population. The most common diagnosis was Ewing's sarcoma (48 [44.9%] patients), followed by chondrosarcoma (33 [30.8%] patients), and osteosarcoma (26 [24.3%] patients). Chondrosarcoma had the highest survival rates with 77.2% and 64.2% 5- and 10-year survival rates, respectively, followed by Ewing's sarcoma with 48.1% and 44.9% 5 and 10-year survival and osteosarcoma with 36.0% and 30.9% 5- and 10-year survival. Conclusions Spinal sarcoma is a rare disease with variable survival depending on the histologic diagnosis. This population-level study involves a heterogeneous group of patients with variable stages of disease at presentation and variable treatments. Our data fit with the published literature for survival for those treated conservatively and surgically. Our data show considerable improvement in 5- and 10-year mortality when compared with previous population level studies on earlier patient cohorts, likely reflecting improvements in systemic and surgical treatments.

BACKGROUND Many acceptable treatment options exist for distal radius fractures (DRFs); however, a simultaneous comparison of all methods is difficult using conventional study designs. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer the following questions: Compared with nonoperative treatment, (1) which intervention is associated with the best 1-year functional outcome? (2) Which intervention is associated with the lowest risk of overall complications? (3) Which intervention is associated with the lowest risk of complications requiring operation? METHODS Ten databases were searched from inception to July 25, 2019. Search and analysis reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies were English-language RCTs that assessed at least one surgical treatment arm for adult patients with displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting on patients with open fractures, extensive bone loss, or ipsilateral upper extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments compared were the volar locking plate, bridging external fixation, nonbridging external fixation, dynamic external fixation, percutaneous pinning, intramedullary fixation, dorsal plating, fragment-specific plating, and nonoperative treatment. Subgroup analyses were conducted for intraarticular fractures, extraarticular fractures, and patients with an average age greater than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar across all treatment groups except for dynamic external fixation (44 years) and fragment-specific plating (47 years). Distribution of intraarticular and extraarticular fractures was approximately equal among the treatment groups other than that for intramedullary fixation (73% extraarticular), fragment-specific plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). Outcomes were the DASH score at 1 year, total complications, and reoperation. The minimum clinically important different (MCID) for the DASH score was set at 10 points. The analysis was performed using Bayesian methodology with random-effects models. Rank orders were generated using surface under the cumulative ranking curve values. Evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology. Most studies had a low risk of bias due to randomization and low rates of incomplete follow-up, unclear risk of bias due to selective reporting, and high risk of bias due to lack of patient and assessor blinding. Studies assessing bridging external fixation and/or nonoperative treatment arms had a higher overall risk of bias while studies with volar plating and/or percutaneous pinning treatment arms had a lower risk of bias. RESULTS Across all patients, there were no clinically important differences in terms of the DASH score at 1 year; although differences were found, all were less than the MCID of 10 points. Volar plating was ranked the highest for DASH score at 1 year (mean difference -7.34 [95% credible interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to -0.56]). The subgroup analysis revealed that only locked volar plating was favored over nonoperative treatment for patients older than 60 years of age (mean difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was uncertain as the MCID was not met. Among all patients, intramedullary fixation (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 0.05 to 0.39]) were associated with a lower complication risk compared with nonoperative treatment. For intraarticular fractures, volar plating was the only treatment associated with a lower risk of complications than nonoperative treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only nonbridging external fixation was associated with a lower risk of complications than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the quality of evidence was low. Among all patients, the risk of complications requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over nonoperative treatment when analyzed by subgroups. CONCLUSION We found no clinically important differences favoring any surgical treatment option with respect to 1-year functional outcome. However, relative to the other options, volar plating was associated with a lower complication risk, particularly in patients with intraarticular fractures, while nonbridging external fixation was associated with a lower complication risk in patients with extraarticular fractures. For patients older than 60 years of age, nonoperative treatment may still be the preferred option because there is no reliable evidence showing a consistent decrease in complications or complications requiring operation among the other treatment options. Particularly in this age group, the decision to expose patients to even a single surgery should be made with caution. LEVEL OF EVIDENCE Level I, therapeutic study.

Background One of the most devastating complications of total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). Although many complications associated with TKA have decreased over time, the trends associated with PJI are less clear. Thus, the purpose of this study is to determine the incidence and risk factors for PJI after primary TKA. Methods We performed a population-based cohort study using linked administrative databases in Ontario, Canada. We used a Cox proportional hazards model to analyze the effect of surgical factors and patient factors on the risk of developing PJI. Results In total, 129,613 patients aged 50+ received a primary TKA for osteoarthritis from 2002 to 2016 in Ontario, Canada. In total, 1.41% of patients underwent revision surgery for PJI. When accounting for censoring, the cumulative incidence for PJI was 0.51% (95% confidence interval 0.46-0.55) at 1 year, 1.12% (1.05-1.18) at 5 years, 1.49% (1.41-1.57) at 10 years, and 1.65% (1.55-1.75) at 15 years. The multivariable model revealed that male gender, younger age, type II diabetes, post-traumatic arthritis, patellar resurfacing, and discharge to convalescent care were associated with increased risk of PJI. Conclusion The risk of PJI following TKA has decreased in small but steady increments over the past 15 years. Most PJIs are diagnosed within the first 2 years postoperatively, though a small group do continue to occur after 10 years. Overall, while the incidence of PJI has decreased slightly over the past 15 years, it remains among the most concerning complications of TKA and continued efforts aimed at further reducing its occurrence are needed.

Importance of the TopicOsteoporotic vertebral fractures can occur without trauma, and cause pain and disability related to decreased mobility [14]. As the North American population ages in the coming decade, osteoporotic vertebral fractures will become more burdensome on patients and healthcare syst

IntroductionPatients with type 2 diabetes mellitus (T2DM) are at risk for a variety of severe debilitating effects. One of the most serious complications experienced by T2DM patients are skeletal diseases caused by changes in the bone microenvironment. As a result, T2DM patients are at risk for higher prevalence of fragility fractures.There are a variety of treatments available for counteracting this effect. Some anti-diabetic medications, such as metformin, have been shown to have a positive effect on bone health without the addition of additional drugs into patients’ treatment plans. Chinese randomized controlled trial (RCT) studies have also proposed antiresorptive pharmacotherapies as a viable alternative treatment strategy. Previous network meta-analyses (NMAs) and meta-analyses regarding this topic did not include all available RCT trials, or only performed pairwise comparisons. We present a protocol for a two-part NMA that incorporates all available RCT data to provide the most comprehensive ranking of anti-diabetics (Part I) and antiresorptive (Part II) pharmacotherapies in terms of their ability to decrease fracture incidences, increase bone mineral density (BMD), improve indications of bone turnover markers (BTMs), and decrease pain in adult T2DM patients.Methods and AnalysisWe will search MEDLINE, EMBASE, PubMed, Web of Science, CINAHL, CENTRAL and Chinese literature sources (CNKI, CQVIP, Wanfang Data, Wanfang Med Online) for randomized controlled trials (RCTs) which fit our criteria. We will include adult T2DM patients who have taken anti-diabetics (Part I) or antiresorptive (Part II) therapies with relevant outcome measures in our study.We will perform title/abstract and full-text screening as well as data extraction in duplicate. Risk of bias (RoB) will be evaluated in duplicate for each study, and the quality of evidence will be examined using CINeMA in accordance to the GRADE framework. We will use R and gemtc to perform the NMA. We will report changes in BMD, BTM and pain scores in either weighted or standardized mean difference, and we will report fracture incidences as odds ratios. We will use the surface under the cumulative ranking curve (SUCRA) scores to provide numerical estimates of the rankings of interventions.Ethics and DisseminationThe study will not require ethics approval. The findings of the two-part NMA will be disseminated in peer-reviewed journals and presented at conferences. We aim to produce the most comprehensive quantitative analysis regarding the management of T2DM bone disease. Our analysis should be able to provide physicians and patients with up-to-date recommendations for anti-diabetic medications and antiresorptive pharmacotherapies for maintaining bone health in T2DM patients.Systematic Review RegistrationInternational Prospective Register for Systematic Reviews (PROSPERO) — CRD42019139320ARTICLE SUMMARYStrengths and limitations of this studyLiterature search in Chinese databases will yield new RCT evidence regarding the efficacy of anti-diabetics in treating T2DM bone diseaseUsing network meta-analytical techniques to analyze the relative efficacy of antiresorptive therapies will allow us to include new treatment arms, such as zoledronic acid and risedronate.Only RCTs will be included and the quality of trials and networks will be evaluated using Risk of Bias, GRADE and comparison-adjusted funnel plots.Chinese clinicians may not use the same procedures and practices as Western clinicians, therefore the outcomes from Chinese RCTs may not apply to the Western healthcare systems.The study design does not allow the comparison of anti-diabetics with antiresorptive therapies or combinations of the two.

Supplemental Digital Content is available in the text, Introduction: Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. Unfortunately, SVG are associated with poor long-term patency rates; a significant predictor of re-operation rates and survival. As such, medical therapy to prevent SVG narrowing or occlusion is of paramount importance. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. We present a protocol for a network meta-analysis (NMA) comparing the effects of various antiplatelet therapy regimens on SVG patency, mortality, and bleeding among adult patients following CABG. Methods: We will search CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC, and grey literature sources (AHA, ACC, ESC, and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. RCTs that evaluate different antiplatelet regimens at least 3-months after CABG and have any of SVG patency, mortality, MACE, and major bleeding as outcomes will be selected. We will perform title and abstract screening, full-text screening, and data extraction independently and in duplicate. Two independent reviewers will also assess risk of bias (ROB) for each study, as well as evaluate quality of evidence using the GRADE framework. We will use R to perform the NMA and use low-dose ASA as reference within our network. We will report results as odds ratios with confidence intervals for direct comparisons, and credible intervals for indirect or mixed comparisons. We will use the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. Discussion: Given the limited direct comparison of various antiplatelet regimens, a network approach is ideal to clarify the optimum antiplatelet therapy after CABG. We hope that our NMA will be the largest quantitative synthesis evaluating antiplatelet regimens among patients requiring CABG. It should inform clinicians and guideline developers in selecting the most effective and safest antiplatelet regimen. Systematic Review registration: International Prospective Register for Systematic Reviews (PROSPERO)—CRD42019127695.

Background. The clinical care of soft-tissue sarcoma (STS) patients is largely multidisciplinary involving clinicians from surgical disciplines, medical oncology, and radiation oncology. It is not clear if treatment patterns for STS have changed over time. We present population-level data on changes in treatment patterns of patients diagnosed with STS of all stages in Ontario, Canada. Methods. We performed a population-based cohort study using linked administrative databases in Ontario, Canada, of patients with STS between 2006 and 2015. Patients with the AJCC stage at the time of diagnosis were included. Patients were categorized into one of the seven treatment arms: single modality treatment (surgery, chemotherapy, or radiation therapy), bimodality therapy, or all three treatment modalities. Survival of STS patients of different stages is displayed with the Kaplan–Meier method. Results. A total of 4696 patients were diagnosed with biopsy-proven sarcoma during the study period including 1915 patients with stage information available. Treatment patterns for patients with Stage 1 and 2 disease were similar enough to allow for grouping. The use of radiation therapy in Stage 1 and 2 patients increased by 15% over the study period. None of the 7 treatment regimens for Stage 3 patients changed appreciably during the study period. We observed that the use of chemotherapy for Stage 4 STS patients increased 36% during the study period. Overall patient survival was, as expected, highest in Stage 1 patients and lowest in Stage 4 patients. Conclusion. This is the first population-level study reporting of 7 different STS treatment regimens in a country with universal and centralized healthcare. Radiation therapy for local disease control and chemotherapy for Stage 4 patients have recently become more utilized. Survival from STS is highly dependent on stage at presentation. Other population-based studies from other countries are needed to establish the current international treatment patterns.

IntroductionPatients with type 2 diabetes mellitus (T2DM) are at risk for a variety of severe debilitating effects. One of the most serious complications experienced by patients with T2DM are skeletal diseases caused by changes in the bone microenvironment. As a result, patients with T2DM are at risk for higher prevalence of fragility fractures. There are a variety of treatments available for counteracting this effect. Some antidiabetic medications, such as metformin, have been shown to have a positive effect on bone health without the addition of additional drugs into patients’ treatment plans. Chinese randomised controlled trial (RCT) studies have also proposed antiosteoporotic pharmacotherapies as a viable alternative treatment strategy. Previous network meta-analyses (NMAs) and meta-analyses regarding this topic did not include all available RCT trials, or only performed pairwise comparisons. We present a protocol for a two-part NMA that incorporates all available RCT data to provide the most comprehensive ranking of antidiabetics (part I) and antiosteoporotic (part II) pharmacotherapies in terms of their ability to decrease fracture incidences, increase bone mineral density (BMD) and improve indications of bone turnover markers (BTMs) in adult patients with T2DM.Methods and analysisWe will search Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials and Chinese literature sources (China National Knowledge Infrastructure, Chongqing VIP Information, Wanfang Data, Wanfang Med Online) for RCTs, which fit our criteria. We will include adult patients with T2DM who have taken antidiabetics (part I) or antiosteoporotic (part II) therapies with relevant outcome measures in our study. We will perform title/abstract and full-text screening as well as data extraction in duplicate. Risk of bias will be evaluated in duplicate for each study, and the quality of evidence will be examined using Confidence in Network Meta-Analysis in accordance to the Grading of Recommendations Assessment, Development and Evaluation framework. We will use R and gemtc to perform the NMA. We will report changes in BMD and BTMs in either weighted or standardised mean difference, and we will report fracture incidences as ORs. We will use the Surface Under the Cumulative Ranking Curve scores to provide numerical estimates of the rankings of interventions.Ethics and disseminationThe study will not require ethics approval. The findings of the two-part NMA will be disseminated in peer-reviewed journals and presented at conferences. We aim to produce the most comprehensive quantitative analysis regarding the management of T2DM bone disease. Our analysis should be able to provide physicians and patients with up-to-date recommendations for antidiabetic medications and antiosteoporotic pharmacotherapies for maintaining bone health in patients with T2DM.PROSPERO registration numberCRD42019139320.

Background The journal impact factor (JIF) is thought to reflect the average number of citations an article will receive and therefore can influence study impact and clinical decision making. However, analysis of citation rates across multiple scientific and research domains has shown that most articles will not reach this expected number of citations. This phenomenon is known as citation skew and it has not previously been examined in the orthopaedic literature. The objective of this study was to determine the extent to which citation skew exists within orthopaedic journals and thus to determine whether the JIF in the orthopaedic literature reflects individual study citation rates. Methods We used data from the Thomson Reuters (now Clarivate Analytics) Web of Science to determine the 2015 JIF and citation distribution for all orthopaedic journals listed in the database. We calculated the percentage of articles with fewer citations than the JIF for each journal. Finally, we analyzed the citation distribution within groups of orthopaedic subspecialty publications. Results We identified a total of 74 orthopaedic journals and 29,296 publications for the years 2013 and 2014. Across all orthopaedic journals, 85% of published articles are cited fewer times than the JIF would indicate. The median number of citations of all articles was zero for all journals (interquartile range = 0-0) except for seven journals, for which the median number of citations per article was 1. Conclusion Citation skew is prevalent across the orthopaedic literature. Most published work is not cited in the first 2 years following publication, and the JIFs are the result of a few highly cited articles. The assessment of an individual orthopaedic study's quality should not be determined by the JIF but rather by direct evaluation of the methodology, relevance, and appropriateness of the study's conclusions.

Background The annual number of retracted publications in the scientific literature is rapidly increasing. The objective of this study was to determine the frequency and reason for retraction of cancer publications and to determine how journals in the cancer field handle retracted articles. Methods We searched three online databases (MEDLINE, Embase, The Cochrane Library) from database inception until 2015 for retracted journal publications related to cancer research. For each article, the reason for retraction was categorized as plagiarism, duplicate publication, fraud, error, authorship issues, or ethical issues. Accessibility of the retracted article was defined as intact, removed, or available but with a watermark over each page. Descriptive data was collected on each retracted article including number of citations, journal name and impact factor, study design, and time between publication and retraction. The publications were screened in duplicated and two reviewers extracted and categorized data. Results Following database search and article screening, we identified 571 retracted cancer publications. The majority (76.4%) of cancer retractions were issued in the most recent decade, with 16.6 and 6.7% of the retractions in the prior two decades respectively. Retractions were issued by journals with impact factors ranging from 0 (discontinued) to 55.8. The average impact factor was 5.4 (median 3.54, IQR 1.8–5.5). On average, a retracted article was cited 45 times (median 18, IQR 6–51), with a range of 0–742. Reasons for retraction include plagiarism (14.4%), fraud (28.4%), duplicate publication (18.2%), error (24.2%), authorship issues (3.9%), and ethical issues (2.1%). The reason for retraction was not stated in 9.8% of cases. Twenty-nine percent of retracted articles remain available online in their original form. Conclusions Retractions in cancer research are increasing in frequency at a similar rate to all biomedical research retractions. Cancer retractions are largely due to academic misconduct. Consequences to cancer patients, the public at large, and the research community can be substantial and should be addressed with future research. Despite the implications of this important issue, some cancer journals currently fall short of the current guidelines for clearly stating the reason for retraction and identifying the publication as retracted.

Giant cell tumor of bone (GCTB) is a benign, locally aggressive, osteolytic lesion. Typical treatment involves extended intralesional curettage or en bloc resection.Denosumab is a fully human monoclonal antibody with inhibitory effects on RANKL (receptor activator of nuclear factor-κB ligand) that h

Magnetic resonance imaging (MRI) has become the gold standard for imaging neurological tissues including the spinal cord. The use of MRI for imaging in the acute management of patients with spinal cord injury has increased significantly. This paper used a vigorous literature review with Downs and Black scoring, followed by a Delphi vote on the main conclusions. MRI is strongly recommended for the prognostication of acute spinal cord injury. The sagittal T2 sequence was particularly found to be of value. Four prognostication patterns were found to be predictive of neurological outcome (normal, single-level edema, multi-level edema, and mixed hemorrhage and edema). It is recommended that MRI be used to direct clinical decision making. MRI has a role in clearance, the ruling out of injury, of the cervical spine in the obtunded patient only if there is abnormality of the neurological exam. Patients with cervical spinal cord injuries have an increased risk of vertebral artery injuries but the literature does not allow for recommendation of magnetic resonance angiography as part of the routine protocol. Finally, time repetition (TR) and time echo (TE) values used to evaluate patients with acute spinal cord injury vary significantly. All publications with MRI should specify the TR and TE values used.

BACKGROUND The open-access model has changed the landscape of academic publishing over the last 20 years. An unfortunate consequence has been the advent of predatory publishing, which exploits the open-access model for monetary gain by collecting publishing fees from authors under the pretense of being a legitimate publication while providing little-to-no peer review. This study aims to investigate the predatory publishing phenomenon in orthopaedic literature. METHODS We searched Beall's List of Predatory Journals and Publishers and another list of predatory journals for journal titles that are possibly related to orthopaedics. We then searched their web sites for the following information: total number of articles published, journal country of origin, author country of origin, article processing charge (APC), quoted review time, and location of the listed headquarters. We also reported the article quality of a random sample of these journals. We consulted InCites Journal Citation Reports to determine the number of nonpredatory orthopaedic publications that are indexed, and we manually searched a random sample of these legitimate journals for Beall's criteria. Additionally, we searched the Directory of Open Access Journals (DOAJ) and PubMed databases for any possible predatory journal titles. RESULTS We found 104 suspected predatory publishers, representing 225 possible predatory journals. One journal was indexed in the DOAJ, and 20 were indexed in PubMed. Review time was not identified for 56.2% of the journals, and 36.5% quoted a review time of

Bisphosphonates have become the first-line treatment for diseases involving excessive osteoclast-mediated bone resorption. However, evidence suggests that elevated doses or prolonged treatment may impair normal skeletal mineralization and may be associated with fractures. The majority of these fractures are located in the subtrochanteric region. This article presents the first described case of atraumatic spinopelvic dissociation related to a combination of osteoporosis and prolonged bisphosphonate use. The current literature also is reviewed, and putative mechanisms and management options are discussed. [ Orthopedics. 2016; 39(4):e753–e755.]

Background: The inferior glenohumeral ligament, the most important static anterior stabilizer of the shoulder, becomes disrupted in humeral avulsion of the glenohumeral ligament (HAGL) lesions. Unfortunately, HAGL lesions commonly go unrecognized. A missed HAGL during an index operation to treat anterior shoulder instability may lead to persistent instability. Currently, there are no large studies describing the indications for surgical repair or the outcomes of patients with HAGL lesions. Purpose: To search the literature to identify surgical indications for the treatment of HAGL lesions and discuss reported outcomes. Study Design: Systematic review; Level of evidence, 4. Methods: Two reviewers completed a comprehensive literature search of 3 online databases (MEDLINE, EMBASE, and Cochrane Library) from inception until May 25, 2016, using the keywords “humeral avulsion of the glenohumeral ligament” or “HAGL” to generate a broad search. Systematic screening of eligible studies was undertaken in duplicate. Abstracted data were organized in table format, with descriptive statistics presented. Results: After screening, 18 studies comprising 118 patients were found that described surgical intervention and outcomes for HAGL lesions. The mean patient was 22 years (range, 12-50 years), and 82% were male. Sports injuries represented 72% of all HAGL injuries. The main surgical indication was primary anterior instability, followed by pain and failed nonoperative management. Commonly associated injuries in patients with identified HAGL lesions included a Bankart lesion (15%), Hill-Sachs lesions (13%), and glenoid bone loss (7%). Reporting of outcome scores varied among the included studies. Meta-analysis was not possible, but all included studies reported significantly improved postoperative stability and function. There were no demonstrated differences in outcomes for patients treated with open versus arthroscopic surgical techniques. All but 2 patients undergoing operative management for HAGL lesions were able to return to sport at their previous levels; these included Olympians and professional athletes. Conclusion: HAGL lesions typically occur in younger male patients and are often associated with Bankart lesions and bone loss. Open and arthroscopic management techniques are both effective in preventing recurrent instability.

Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder of increasing prevalence, particularly within patients aged younger than 10 years. When present in these younger patients, SCFE is usually associated with metabolic abnormality or endocrinopathy. We present a case of a 5-year-old boy with idiopathic SCFE who underwent staged bilateral pinning in situ using a uniquely modified smooth wire for fixation across the physis. He eventually required bilateral screw revision after outgrowing the initial screws. At follow-up 3 years later, the patient was pain free with satisfactory hardware placement. He will be closely monitored, as he will likely need further surgical revision once he outgrows the second set of fixation screws.