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Background: Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients.Methods: As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects.Results: In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication.Conclusions: Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols.Level Of Evidence: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Fracture liaison services focus on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. This study describes key clinical outcomes including bone mineral densitometry, physician assessment, and pharmacotherapy initiation in pharmacotherapy-naïve patients undergoing treatment for fragility fracture in a Canadian fracture liaison service.Methods: We determined rates of post-fracture investigation and treatment for inpatients and outpatients with a fragility fracture seen in a coordinator-based fracture liaison service at an urban university trauma hospital. The program identified distal radial, proximal femoral, proximal humeral, and vertebral fragility fractures in female patients ≥40 years of age and male patients ≥50 years of age and provided education, bone mineral densitometry, inpatient consultation or outpatient specialist or primary care physician referral for bone health management, and documented patient follow-up.Results: The 2,191 patients with a fragility fracture were not taking anti-osteoporosis pharmacotherapy at the time of identification (862 inpatients and 1,329 outpatients). Eighty-four percent of inpatients and 85% of outpatients completed a bone mineral densitometry as recommended. Fifty-two percent of patients with proximal femoral fracture, 29% of patients with vertebral fracture, 26% of patients with proximal humeral fracture, and 20% of patients with distal radial fracture had osteoporosis confirmed on the basis of a bone mineral densitometry T-score of ≤-2.5 at the femoral neck or L1 to L4. Eighty-five percent of inpatients and 79% of outpatients referred for bone health management were assessed by a specialist or primary care physician. Of the patients who attended their appointments, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.Conclusions: A high rate of education, evaluation, and pharmacological treatment, if indicated, can be achieved through a coordinator-facilitated fracture liaison service program.Clinical Relevance: Fracture prevention programs are currently engaged in establishing and modifying fracture liaison services in a quest for practical and effective models. The program described in this article exemplifies a coordinator-based model that produced good outcomes. [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]

Objective: The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients. Methods: A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association. Results: Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients. Conclusion: Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients. [ABSTRACT FROM AUTHOR]

Background: Fragility fractures resulting from osteoporosis are common injuries. However, the identification and treatment of osteoporosis in these high-risk patients are widely reported to be inadequate. The goals of this study were to determine how many patients receiving inpatient or outpatient treatment for a fragility fracture could be identified and enrolled in a program for osteoporosis education, investigation, and treatment and receive appropriate osteoporosis care within the program. Methods: An Osteoporosis Exemplary Care Program was implemented to identify, educate, evaluate, refer, and treat patients considered to be at risk for osteoporosis because of a typical fragility fracture. System modifications included coordination among the orthopaedic unit, Metabolic Bone Disease Clinic, and nuclear medicine unit to provide a continuum of care for these patients. Barriers were addressed through ongoing education of physicians, staff, and patients to increase knowledge and awareness of osteoporosis. The percentages of patients previously diagnosed and treated for osteoporosis, referred for investigation of osteoporosis, treated by the orthopaedic team, and receiving appropriate attention for osteoporosis were calculated. Risk factors for osteoporosis were also assessed. Results: Three hundred and forty-nine patients with a fragility fracture (221 outpatients and 128 inpatients) who met the inclusion criteria and an additional eighty-one patients with a fracture (fifty-five outpatients and twenty-six inpatients) who did not meet the inclusion criteria but were suspected by their orthopaedic surgeons of having underlying osteoporosis were enrolled in the Osteoporosis Exemplary Care Program. More than 96% (414) of these 430 patients received appropriate attention for osteoporosis. Approximately one-third (146) of the 430 patients had been diagnosed and treated for osteoporosis before the time of recruitment. Two hundred and twenty-two of the remaining patients were referred to the Metabolic Bone Disease Clinic or to their family physician for further investigation and treatment for osteoporosis. Treatment was initiated by the orthopaedic team for another twenty-three patients. Many patients had risk factors for osteoporosis in addition to the fragility fracture; these included a previous fracture (forty-nine of 187; 26%), a mother who had had a fragility fracture (forty-two of 188; 22%), or a history of smoking (105 of 188; 56%). Conclusions: In a coordinated post-fracture osteoporosis education and treatment program directed at patients with a fragility fracture and their caregivers, >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care. To accomplish this, a dedicated coordinator and the full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied health-care professionals (nurses, physical and occupational therapists, and social workers), and administrative staff were required. [ABSTRACT FROM AUTHOR]

Determines whether patient satisfaction can be improved by changing patients' expectations of the clinic visit by decreasing the total time spent in the clinic. Patient demographics; Contributing factors that decrease patients' satisfaction with clinic time; Mechanics of intervention strategy.

To understand immediate and long-term outcomes following hip fracture surgery in adults with schizophrenia. Retrospective population-based cohort study leveraging health administrative databases from Ontario, Canada. Individuals aged 40–105 years with hip fracture surgery between April 1, 2009 and March 31, 2019 were included. Schizophrenia was ascertained using a validated algorithm. Outcomes were: 30-day mortality; 30-day readmission; 1-year survival; and subsequent hip fracture within 2 years. Analyses incorporated Generalized Estimating Equation models, Kaplan-Meier curves, and Fine-Gray competing risk models. In this cohort study of 98,126 surgically managed hip fracture patients, the median [IQR] age was 83[75–89] years, 69.2% were women, and 3700(3.8%) had schizophrenia. In Fine-Gray models, schizophrenia was associated with subsequent hip fracture (sd RH, 1.29; 95% CI, 1.09–1.53), with male patients with schizophrenia sustaining a refracture 50 days earlier. In age- and sex-adjusted GEE models, schizophrenia was associated with 30-day mortality (OR, 1.31; 95% CI, 1.12–1.54) and readmissions (OR, 1.40; 95% CI, 1.25–1.56). Kaplan-Meier survival curves suggested that patients with schizophrenia were less likely to be alive at 1-year. Study highlights the susceptibility of hip fracture patients with schizophrenia to worse outcomes, including refracture, with implications for understanding modifiable processes of care to optimize their recovery. • Hip fracture patients with schizophrenia have a higher incidence of subsequent hip fracture. • The onset of subsequent hip fracture is significantly earlier in men with schizophrenia. • Immediate secondary fracture prevention in hip fracture patients with schizophrenia is warranted. [ABSTRACT FROM AUTHOR]

Background: The Fracture Screening and Prevention Program (FSPP), a fracture liaison service (FLS), was implemented in the province of Ontario, Canada, in 2007 to prevent recurrent fragility fractures and to improve post-fracture care. The objective of this analysis was to determine the cost-effectiveness of the current model of the FSPP compared with usual care (no program) from the perspective of the universal public health-care payer (Ontario Ministry of Health and Long-Term Care [MOHLTC]), over the lifetime of older adults who presented with a fragility fracture of the proximal part of the femur, the proximal part of the humerus, or the distal part of the radius and were not taking medications to prevent or slow bone loss and reduce the risk of fracture (bone active medications).Methods: We developed a state-transition (Markov) model to conduct a cost-effectiveness analysis of the FSPP in comparison with usual care. The model simulated a cohort of patients with a fragility fracture starting at 71 years of age. Model parameters were obtained from published literature and from the FSPP. Quality-adjusted life-years (QALYs) and costs in 2018 Canadian dollars were predicted over a lifetime horizon using a 1.5% annual discount rate. Health outcomes included subsequent proximal femoral, vertebral, proximal humeral, and distal radial fractures. Scenario and subgroup analyses were reported.Results: The FSPP had lower expected costs ($277 less) and higher expected effectiveness (by 0.018 QALY) than usual care over the lifetime horizon. Ninety-four percent of the 10,000 Monte Carlo simulated incremental cost-effectiveness ratios (ICERs) demonstrated lower costs and higher effectiveness of the FSPP.Conclusions: The FSPP appears to be cost-effective compared with usual care over a lifetime for patients with fragility fracture. This information may help to quantify the value of the FSPP and to assist policy-makers in deciding whether to expand the FSPP to additional hospitals or to initiate similar programs where none exist.Level Of Evidence: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article highlights postfracture osteoporosis care in Canada. A poll suggests that Canadian orthopedic surgeons are generally aware of and motivated to provide appropriate osteoporosis care as a legitimate component of postfracture care. A pressing need is for systems and resources to facilitate osteoporosis care in orthopedic clinic and ward. The best model of postfracture osteoporosis care is the coordinator-based model.

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]

Background: Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture. Methods: A cohort of patients with a hip fracture between 2016–2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery. Results: In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73–87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60–0.92), 60s (OR:0.81, 95%CI:0.70–0.94) and 70s (OR:0.89, 95%CI:0.81–0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race. Interpretation: Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted. [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]

Background: Compromised bone health is often associated with depression and chronic pain. Objective: To examine: (1) the experience of existing depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain. Design: A phenomenological study guided by Giorgi's analytical procedures. Setting and Participants: Fracture patients who reported taking prescription medication for one or more comorbidities, excluding compromised bone health. Main Variables Studied: Patients were interviewed within 6 weeks of their fracture, and 1 year later. Interview questions addressed the recent fracture and patients' experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions. Results: Twenty‐six patients (5 men, 21 women) aged 45–84 years old with hip (n = 5) and nonhip (n = 21) fractures were recruited. Twenty‐one participants reported depression and/or chronic nonfracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent, based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. Conclusion: Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients' more general emotional and physical state. Patient Contribution: A patient representative was involved in the study conception, data interpretation and manuscript writing. [ABSTRACT FROM AUTHOR]

Information about several topics discussed at the Combined Annual Meeting of the American Orthopaedic Association and the Canadian Orthopaedic Association in Quebec City held on June 2008. Topics include to discussion of an aging population and workforce as well as changing disease patterns and treatment option. In addition, it also summarizes the four aspects of orthopaedics including fragility fractures, hip and knee replacement surgery and pediatric orthopaedics.

Objective: The orthopedic community is in a unique position to initiate and provide osteoporosis care in fragility fracture patients to prevent future hip fractures in a high-risk population. The attitudes and intentions of Canadian orthopedic surgeons in the domain of osteoporosis care are unknown. Our objective was to identify current attitudes and osteoporosis management practices and to determine their overall willingness to participate in osteoporosis care for fragility fracture patients.Methods: A real-time interactive polling session was conducted at the 58th Annual Meeting of the Canadian Orthopaedic Association.Results: Of the orthopedic surgeons who responded, 90.4% agreed that the current emphasis on osteoporosis in orthopedic practice is appropriate; 85.2% of surgeons indicated that they currently refer or personally investigate for osteoporosis, or both, in fragility fracture patients.Conclusion: Most of the Canadian orthopedic surgeons sampled consider themselves to be currently engaged or ready to engage in osteoporosis care for fragility fracture patients. Focus should now shift from education and persuasion to program support through provision of resources and system modification that will enable Canadian orthopedic surgeons to effectively manage osteoporosis in their fracture patients. [ABSTRACT FROM AUTHOR]

Abstract: Objectives. – To quantify asymmetry of radiological joint damage in rheumatoid arthritis (RA), to determine whether asymmetrical damage to joints in RA becomes symmetrical over time, and to identify factors predictive of symmetrization. Patients and methods. – In phase 1, initial, mid-term (mean follow-up: three years) and late (mean follow-up: eight years) radiographs of 48 patients with definite RA (English population) were graded by the Modified Larsen (ML) system. In phase 2, 27 subjects (Canadian population) with at least one asymmetrical pair of joints in the hands or feet were identified. Two successive radiographs of 77 asymmetrical joints, separated by at least two years, were compared. Clinical and biological factors were assessed for their ability to predict symmetrization, defined as a reduction in side-to-side difference over time of two or more ML grades. Results. – In phase 1, the overall rate of asymmetry was 12.9% (95% C.I.: 11.2%–14.5%), increasing from 9.7% (first visit) to 13.8% (mid-term) and 14.4% (last visit). Metacarpophalangeal (MCP) joints were more frequently asymmetrical than thumb (MCP and interphalangeal) joints (p=0.0064) and proximal interphalangeal (PIP) joints (p<0.0001); wrist quadrants were more frequently asymmetrical than PIP joints (p<0.0001). In phase 2, two groups were identified and compared: symmetrizers (22 joints) and non-symmetrizers (55 joints). The overall probability of small joints in the hand and foot symmetrizing was 28.5%. Rheumatoid factor (RF) was predictive of symmetrization. The risk of symmetrization was significantly increased in RF-positive patients with asymmetric joints (p=0.01). The prevalence of asymmetry did not decrease with disease duration, despite symmetrization. Conclusions. – Prevalence of asymmetry in joint damage in RA was 13 to 16%. Symmetry was more evident in PIP joints than in MCP and wrist joints. Seropositive patients are more than twice as likely to symmetrize than seronegative patients. Data regarding the tendency for symmetrization may have value in the clinical management of RA patients with asymmetrical joint damage. [Copyright &y& Elsevier]

Objectives: To quantify asymmetry of radiological joint damage in rheumatoid arthritis (RA), to determine whether asymmetrical damage to joints in RA becomes symmetrical over time, and to identify factors predictive of symmetrization.Methods: In phase 1, initial, mid-term (mean follow-up: 3 years) and late (mean follow-up: 8 years) radiographs of 48 patients with definite RA (English population) were graded by the Modified Larsen (ML) system. In phase 2, 27 subjects (Canadian population) with at least one asymmetrical pair of joints in the hands or feet were identified. Two successive radiographs of 77 asymmetrical joints, separated by at least 2 years, were compared. Clinical and biological factors were assessed for their ability to predict symmetrization, defined as a reduction in side-to-side difference over time of two or more ML grades.Results: In phase 1, the overall rate of asymmetry was 12.9% (95% CI: 11.2-14.5%), increasing from 9.7% (first visit) to 13.8% (mid-term) and 14.4% (last visit). Metacarpophalangeal (MCP) joints were more frequently asymmetrical than thumb (MCP and interphalangeal) joints (P = 0.0064) and proximal interphalangeal (PIP) joints (P < 0.0001); wrist quadrants were more frequently asymmetrical than PIP joints (P < 0.0001). In phase 2, two groups were identified and compared: symmetrizers (22 joints) and non-symmetrizers (55 joints). The overall probability of small joints in the hand and foot symmetrizing was 28.5%. Rheumatoid factor (RF) was predictive of symmetrization. The risk of symmetrization was significantly increased in RF-positive patients with asymmetric joints (P = 0.01). The prevalence of asymmetry did not decrease with disease duration, despite symmetrization.Conclusions: Prevalence of asymmetry in joint damage in RA was 13-16%. Symmetry was more evident in PIP joints than in MCP and wrist joints. Seropositive patients are more than twice as likely to symmetrize than seronegative patients. Data regarding the tendency for symmetrization may have value in the clinical management of RA patients with asymmetrical joint damage. [ABSTRACT FROM AUTHOR]

AbstractBackground: Many patients who have undiagnosed osteoporosis and a recent fragility fracture present to fracture clinics in Canadian hospitals, where the focus of management is on fracture care. The rate of diagnosis and treatment of osteoporosis in this patient group is unknown.Methods: Patients who presented with fractures at sites consistent with fragility-type fractures were identified through a retrospective chart review of fracture clinic visits in 3 Ontario community hospitals in selected weeks in February and November 1996 and August and May 1997. These patients were contacted by mail and telephone follow-up to obtain consent to participate in a telephone interview. Patients were excluded if the index fracture had been traumatic, if they were younger than 18 years, or if they had medical conditions known to be associated with secondary bone loss. Eligible patients were questioned about their history of prior fractures, diagnosis of osteoporosis, and investigation and treatment of osteoporosis before or after the index fracture.Results: Among 2694 fracture clinic visits, we identified 228 patients (8.4%) with fragility-type fractures. Of the 228, 128 (56.1%) were contacted and agreed to participate in an interview about 1 year from the date of the index fracture. Of the 128 patients, 108 (83 postmenopausal and 13 premenopausal women and 12 men) were confirmed as eligible. Of the 108, 43 had experienced 53 fractures in addition to the index fracture in the preceding 10 years, of which 71% were of the fragility type. At interview, only 20 (18.5%) (all postmenopausal women) of the 108 patients reported that they had received a diagnosis of osteoporosis. Of the 20, 90% and 45% respectively had been advised to take calcium and vitamin D supplements; 8 (40%) were receiving hormone replacement therapy (HRT), and 8 (40%) were taking bisphosphonates. Of the 88 patients who had not received a diagnosis of osteoporosis, 4 (4.5%) were receiving HRT, none was ta... [ABSTRACT FROM AUTHOR]

Background: We sought to report the prevalence of fragility fracture patients who were screened at high falls risk using a large provincial database, and to determine the characteristics associated with being screened at high falls risk.Methods: The study population included fragility fracture patients 50+ years of age who were screened at 35 hospital fracture clinics in Ontario over a 3.5 year period. The outcome was based on two screening questions measuring the risk of falling, both adapted from the STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool. Multivariable associations of sociodemographic, fracture-related, and health-related characteristics were evaluated using logistic regression.Results: Of the sample, 9735 (44.5%) patients were classified as being at high falls risk, and 12,089 (55.3%) were not. In the multivariable logistic regression, being 80+ years of age (vs. 50-64 years of age), non-community dwelling (vs. living with spouse, family member, roommate), having a mental/physical impairment (vs. none), and taking multiple medications, were all strongly associated with being screened at high falls risk.Conclusions: Living in a non-community dwelling and taking 4+ medications were the variables most strongly associated with being screened at high falls risk. These are potentially modifiable characteristics that should be considered when assessing falls risk in fragility fracture patients, and particularly when designing interventions for preventing subsequent falls. Ongoing work to address the higher risk of falls in the fragility fracture population is warranted. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups.Study Design and Methods: A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury ). Outcomes were compared in pre- and post-protocol groups with χ2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex).Results: No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451).Conclusions: Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS: A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury). Outcomes were compared in pre‐ and post‐protocol groups with χ2 analysis. Logistic regression compared risk of transfusion in pre‐ and post‐protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS: No differences were found in baseline patient characteristics across pre‐ and post‐protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post‐protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS: Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy. [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]

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 To determine the relationship between surgeon experience with, and complications following, total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA). Methods Using administrative data, we assembled a cohort of patients with RA who had undergone at least 1 elective primary hip or knee replacement procedure between 2002 and 2009. Cox proportional hazards, censored on death and accounting for clustering of patients within surgeons, were used to determine the relationship between overall and 'RA-specific' surgeon TJA volume and the occurrence of a composite 'complication' outcome (revision, infection, dislocation, or periprosthetic fracture within 2 years of the initial TJA), controlling for potential confounders (patient age, sex, comorbidity, and disease severity). Results We identified 4,762 patients with RA who were eligible for TJAs (1,515 total hip arthroplasties and 3,247 total knee arthroplasties). Among these patients, 152 (3.2%) experienced a surgical complication within 2 years of the procedure. After controlling for patient and hospital factors, greater surgeon TJA volume in patients with RA (RA TJA), but not overall TJA volume (all TJA), was associated with a reduced risk of complications (for surgeon RA TJA volume per 10 cases, adjusted hazard ratio [HR] 0.81, 95% confidence interval [95% CI] 0.71-0.93, P = 0.002; for surgeon all TJA volume, adjusted HR 0.98, 95% CI 0.97-1.00, P = 0.09). Conclusion In a cohort of patients with RA who underwent hip or knee TJA, increased surgeon experience performing TJA in patients with RA, irrespective of their overall TJA experience and hospital factors, was associated with a decreased risk of surgical complications. These findings have potential implications for surgeon training and the referral practices of rheumatologists. [ABSTRACT FROM AUTHOR]

Objective Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are based on patients with osteoarthritis (OA); less is known about outcomes in rheumatoid arthritis (RA). Using a validated algorithm for identifying patients with RA, we undertook this study to compare the rates of complications among THA and TKA recipients between those with RA and those without RA. Methods In patients who underwent a first primary elective THA or TKA between 2002 and 2009, those with RA were identified using a validated algorithm: a hospitalization with a diagnosis code for RA or 3 physician billing claims with a diagnosis code for RA, with at least 1 claim by a specialist (rheumatologist, orthopedic surgeon, or internist) in a 2-year period. Recipients with diagnostic codes suggesting an inflammatory arthritis, but not meeting RA criteria, were classified as having inflammatory arthritis. All remaining patients were deemed to have OA. Cox proportional hazards models, censored on death, were used to determine the relationship between the type of arthritis and the occurrence of specific complications, adjusting for potential confounders (age, sex, comorbidity, and provider volume). Results We identified 43,997 eligible THA recipients (3% with RA) and 71,793 eligible TKA recipients (4% with RA). Total joint arthroplasty recipients with RA had higher age and sex-standardized rates of dislocation following THA (2.45%, compared with 1.21% for recipients with OA) and higher age and sex-standardized rates of infection following TKA (1.26%, compared with 0.84% for recipients with OA). Controlling for potential confounders, recipients with RA remained at increased risk of dislocation within 2 years of THA (adjusted hazard ratio [HR] 1.91, P = 0.001) and remained at increased risk of infection within 2 years of TKA (adjusted HR 1.47, P = 0.03) relative to recipients with OA. Conclusion Patients with RA are at higher risk of dislocation following THA and are at higher risk of infection following TKA relative to those with OA. Further research is warranted to elucidate explanations for these findings, including the roles of medication profile, implant choice, postoperative antibiotic protocol, and method of rehabilitation following joint replacement. [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]

Objective: To examine the methods used to calculate the reported medication initiation rates in secondary fracture prevention programs. Study Design and Setting: A systematic review was conducted on postfracture interventions that aimed to improve osteoporosis management in an orthopedic environment. Two authors independently reviewed eligible articles to determine the numerator and denominator used to calculate the rates of antiresorptive medication initiation based on author reports. In interventions with numerator and denominator combinations that appeared to be comparable, we examined the inclusion and exclusion criteria to confirm comparability. Results: Fifty-seven articles reporting on 64 interventions were eligible for the review. A total of 28 different combinations of numerators and denominators to calculate rates were reported for medication initiation across 49 of the 64 interventions. After examining the inclusion and exclusion criteria for rates that appeared to be comparable, the highest number of interventions with a comparable rate was 3. Conclusion: Reporting processes for antiresorptive medication initiation outcomes in secondary fracture prevention programs used heterogeneous standards that prevented useful comparison of programs. Applying different numerator and denominator combinations meant that the same observed number of patients could have resulted in different reported rates. We propose standards for reporting medication initiation rates in such programs. [ABSTRACT FROM AUTHOR]

Background: Fractures associated with bone fragility in older adults signal the potential for secondary fracture. Fragility fractures often precipitate further decline in health and loss of mobility, with high associated costs for patients, families, society and the healthcare system. Promptly initiating a coordinated, comprehensive pharmacological bone health and falls prevention program post-fracture may improve osteoporosis treatment compliance; and reduce rates of falls and secondary fractures, and associated morbidity, mortality and costs. Methods/design: This pragmatic, controlled trial at 11 hospital sites in eight regions in Quebec, Canada, will recruit community-dwelling patients over age 50 who have sustained a fragility fracture to an intervention coordinated program or to standard care, according to the site. Site study coordinators will identify and recruit 1,596 participants for each study arm. Coordinators at intervention sites will facilitate continuity of care for bone health, and arrange fall prevention programs including physical exercise. The intervention teams include medical bone specialists, primary care physicians, pharmacists, nurses, rehabilitation clinicians, and community program organizers. The primary outcome of this study is the incidence of secondary fragility fractures within an 18-month follow-up period. Secondary outcomes include initiation and compliance with bone health medication; time to first fall and number of clinically significant falls; fall-related hospitalization and mortality; physical activity; quality of life; fragility fracture-related costs; admission to a long term care facility; participants' perceptions of care integration, expectations and satisfaction with the program; and participants' compliance with the fall prevention program. Finally, professionals at intervention sites will participate in focus groups to identify barriers and facilitating factors for the integrated fragility fracture prevention program. This integrated program will facilitate knowledge translation and dissemination via the following: involvement of various collaborators during the development and set-up of the integrated program; distribution of pamphlets about osteoporosis and fall prevention strategies to primary care physicians in the intervention group and patients in the control group; participation in evaluation activities; and eventual dissemination of study results. Study/trial registration: Clinical Trial.Gov NCT01745068 Study ID number: CIHR grant # 267395 [ABSTRACT FROM AUTHOR]

Objective Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA. Methods Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively. Results Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity). Conclusion The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA. [ABSTRACT FROM AUTHOR]

Background: Patients' values and preferences are fundamental tenets of evidence-based practice, yet current osteoporosis (OP) clinical guidelines pay little attention to these issues in therapeutic decision making. This may be in part due to the fact that few studies have examined the factors that influence the initial decision to take OP medication. The purpose of our study was to examine patients' experiences with the decision to take OP medication after they sustained a fracture. Methods: A phenomenological qualitative study was conducted with outpatients identified in a university teaching hospital fracture clinic OP program. Individuals aged 65+ who had sustained a fragility fracture within 5 years, were 'high risk' for future fracture, and were prescribed OP medication were eligible. Analysis of interview data was guided by Giorgi's methodology. Results: 21 patients (6 males, 15 females) aged 65-88 years participated. All participants had low bone mass; 9 had OP. Fourteen patients were taking a bisphosphonate while 7 patients were taking no OP medications. For 12 participants, the decision to take OP medication occurred at the time of prescription and involved minimal contemplation (10/12 were on medication). These patients made their decision because they liked/trusted their health care provider. However, 4/10 participants in this group indicated their OP medication-taking status might change. For the remaining 9 patients, the decision was more difficult (4/9 were on medication). These patients were unconvinced by their health care provider, engaged in risk-benefit analyses using other information sources, and were concerned about side effects; 7/9 patients indicated that their OP medication-taking status might change at a later date. Conclusions: Almost half of our older patients who had sustained a fracture found the decision to take OP medication a difficult one. In general, the decision was not considered permanent. Health care providers should be aware of their potential role in patients' decisions and monitor patients' decisions over time. [ABSTRACT FROM AUTHOR]

Background: Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease.Methods: We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible.Results: Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely to have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline.Conclusions: A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation. [ABSTRACT FROM AUTHOR]

Background: Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease. Methods: We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible. Results: Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely t, have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline. Conclusions: A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Behaviour change models suggest that people need clear information about their susceptibility to disease and knowledge of treatment recommendations in order to change their behaviour. The purpose of this qualitative study was to examine fracture patients' understanding of osteoporosis (OP) and OP care after being screened for, and educated about, OP in a fracture clinic. Methods We conducted five focus groups with 24 patients (18 women, six men) aged 47–80 years old who were screened for OP through an urban fracture clinic. Participants were asked about their awareness of OP and their status of bone mineral density (BMD) testing and OP treatment. Results Twenty participants vocalized at least one expression of ambiguity regarding OP and/or treatment recommendations conveyed by the screening programme staff. Participants were ambiguous about the cause of their fracture, the BMD test process and results, and the presentation of OP. They were also ambiguous about the amount and type of medication and supplements recommended. Conclusions Despite a standardized screening programme in which OP was addressed in fragility fracture patients, ambiguity about diagnosis, testing and treatment were described. Efforts to clarify information relayed to fracture patients about their condition and recommended care need to extend beyond the fracture clinic so that health care providers can promote long-term adherence to these recommendations. [ABSTRACT FROM AUTHOR]

Background: The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture.Methods: A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness.Results: Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered.Conclusions: Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective. [ABSTRACT FROM AUTHOR]

Background: The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture. Methods: A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness. Results: Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered. Conclusions: Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective. Level of Evidence: Economic and decision analysis, Level I. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Fragility fractures resulting from osteoporosis are common injuries. However, the identification and treatment of osteoporosis in these high-risk patients are widely reported to be inadequate. The goals of this study were to determine how many patients receiving inpatient or outpatient treatment for a fragility fracture could be identified and enrolled in a program for osteoporosis education, investigation, and treatment and receive appropriate osteoporosis care within the program.Methods: An Osteoporosis Exemplary Care Program was implemented to identify, educate, evaluate, refer, and treat patients considered to be at risk for osteoporosis because of a typical fragility fracture. System modifications included coordination among the orthopaedic unit, Metabolic Bone Disease Clinic, and nuclear medicine unit to provide a continuum of care for these patients. Barriers were addressed through ongoing education of physicians, staff, and patients to increase knowledge and awareness of osteoporosis. The percentages of patients previously diagnosed and treated for osteoporosis, referred for investigation of osteoporosis, treated by the orthopaedic team, and receiving appropriate attention for osteoporosis were calculated. Risk factors for osteoporosis were also assessed.Results: Three hundred and forty-nine patients with a fragility fracture (221 outpatients and 128 inpatients) who met the inclusion criteria and an additional eighty-one patients with a fracture (fifty-five outpatients and twenty-six inpatients) who did not meet the inclusion criteria but were suspected by their orthopaedic surgeons of having underlying osteoporosis were enrolled in the Osteoporosis Exemplary Care Program. More than 96% (414) of these 430 patients received appropriate attention for osteoporosis. Approximately one-third (146) of the 430 patients had been diagnosed and treated for osteoporosis before the time of recruitment. Two hundred and twenty-two of the remaining patients were referred to the Metabolic Bone Disease Clinic or to their family physician for further investigation and treatment for osteoporosis. Treatment was initiated by the orthopaedic team for another twenty-three patients. Many patients had risk factors for osteoporosis in addition to the fragility fracture; these included a previous fracture (forty-nine of 187; 26%), a mother who had had a fragility fracture (forty-two of 188; 22%), or a history of smoking (105 of 188; 56%).Conclusions: In a coordinated post-fracture osteoporosis education and treatment program directed at patients with a fragility fracture and their caregivers, >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care. To accomplish this, a dedicated coordinator and the full cooperation of orthopaedic surgeons and residents, orthopaedic technologists, allied health-care professionals (nurses, physical and occupational therapists, and social workers), and administrative staff were required. [ABSTRACT FROM AUTHOR]

Objectives. – To evaluate observer agreement using the Larsen system (LS) and a modified Larsen system (ML) when assessing individual joints of the hands and wrists in rheumatoid arthritis, and to compare the two systems. To determine the minimally important difference (MID) for the ML.Methods. – Thirty radiographs of hands and wrists from 10 patients who presented with RA were graded by two blinded observers, using the LS and then the ML. Patients were followed for a mean of 7.2 years (range: 4–10 years). Inter- and intra-observer agreement were calculated using the kappa statistic with linear incremental weights. Inter-observer agreement was also computed for the summed score, using an intra-class correlation coefficient. Inter-observer error was estimated by calculating the mean and standard deviation of the grading differences between the two observers. Prevalence of damage was calculated as a ratio of damage:no damage and expressed as a percentage. Pairs of radiographs were comparatively graded using a 7-point Likert scale.Results. – The kappa statistic for inter-observer agreement was 0.38 (marginal reproducibility) for the LS and 0.52 (good reproducibility) for the ML (P = 0.004). Using a difference of one grade as perfect agreement, it was 0.56 (good reproducibility) for the LS and 0.87 (excellent reproducibility) for the ML (P = 0.001). Intra-observer agreement was high in both systems. The distribution of ML-grade differences varied according to the level of the Likert scale: for “a little bit worse”, representing the smallest amount of detectable damage progression, the distribution differences peaked around two grades. This value represented a MID 87% of the time.Conclusions. – The LS lacks precision for individual joints. The ML, it is proposed, has more detailed definitions of grades, and is more reliable. When pairs of radiographs were compared, a two-grade difference on the ML was the MID. [Copyright &y& Elsevier]

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]

Background Prosthetic hip and knee joint infections (PJIs) are challenging to eradicate despite prosthesis removal and antibiotic therapy. There is a need to understand risk factors for PJI treatment failure in the setting of prosthesis removal. Methods A retrospective cohort of individuals who underwent prosthesis removal for a PJI at 5 hospitals in Toronto, Canada, from 2010 to 2014 was created. Treatment failure was defined as recurrent PJI, amputation, death, or chronic antibiotic suppression. Potential risk factors for treatment failure were abstracted by chart review and assessed using a Cox proportional hazards model. Results A total of 533 individuals with prosthesis removal were followed for a median (interquartile range) of 814 (235–1530) days. A 1-stage exchange was performed in 19% (103/533), whereas a 2-stage procedure was completed in 88% (377/430). Treatment failure occurred in 24.8% (132/533) at 2 years; 53% (56/105) of recurrent PJIs were caused by a different bacterial species. At 4 years, treatment failure occurred in 36% of 1-stage and 32% of 2-stage procedures (P =.06). Characteristics associated with treatment failure included liver disease (adjusted hazard ratio [aHR], 3.12; 95% confidence interval [CI], 2.09–4.66), the presence of a sinus tract (aHR, 1.53; 95% CI, 1.12–2.10), preceding debridement with prosthesis retention (aHR, 1.68; 95% CI, 1.13–2.51), a 1-stage procedure (aHR, 1.72; 95% CI, 1.28–2.32), and infection due to Gram-negative bacilli (aHR, 1.35; 95% CI, 1.04–1.76). Conclusions Failure of PJI therapy is common, and risk factors are not easily modified. Improvements in treatment paradigms are needed, along with efforts to reduce orthopedic surgical site infections. [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.

Background: Fractures associated with bone fragility in older adults signal the potential for secondary fracture. Fragility fractures often precipitate further decline in health and loss of mobility, with high associated costs for patients, families, society and the healthcare system. Promptly initiating a coordinated, comprehensive pharmacological bone health and falls prevention program post-fracture may improve osteoporosis treatment compliance; and reduce rates of falls and secondary fractures, and associated morbidity, mortality and costs.Methods/design: This pragmatic, controlled trial at 11 hospital sites in eight regions in Quebec, Canada, will recruit community-dwelling patients over age 50 who have sustained a fragility fracture to an intervention coordinated program or to standard care, according to the site. Site study coordinators will identify and recruit 1,596 participants for each study arm. Coordinators at intervention sites will facilitate continuity of care for bone health, and arrange fall prevention programs including physical exercise. The intervention teams include medical bone specialists, primary care physicians, pharmacists, nurses, rehabilitation clinicians, and community program organizers.The primary outcome of this study is the incidence of secondary fragility fractures within an 18-month follow-up period. Secondary outcomes include initiation and compliance with bone health medication; time to first fall and number of clinically significant falls; fall-related hospitalization and mortality; physical activity; quality of life; fragility fracture-related costs; admission to a long term care facility; participants' perceptions of care integration, expectations and satisfaction with the program; and participants' compliance with the fall prevention program. Finally, professionals at intervention sites will participate in focus groups to identify barriers and facilitating factors for the integrated fragility fracture prevention program.This integrated program will facilitate knowledge translation and dissemination via the following: involvement of various collaborators during the development and set-up of the integrated program; distribution of pamphlets about osteoporosis and fall prevention strategies to primary care physicians in the intervention group and patients in the control group; participation in evaluation activities; and eventual dissemination of study results. [ABSTRACT FROM AUTHOR]