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Purpose: Same-day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. Methods: A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between 01 April 2019 and 31 March 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. Results: The cohort consisted of 527 consecutive patients. 101 (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). 2 individual surgeons, later operative start time (OR 1.3; 95% CI, 1.15–1.55; p = 0.001), ASA class IV (OR 3.4; 95% CI, 1.4–8.2; p = 0.006) and undergoing a THA (OR 2.0; 95% CI, 1.2–3.1, p = 0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anaesthetic were found ( p > 0.05). The 30-day readmission or 6-month reoperation were similar between groups ( p > 0.05). Conclusions: Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Background: Total knee arthroplasty (TKA) and total hip arthroplasty (THA), are the second and third most common surgical procedures performed in Canada, accounting for more than 600,000 acute care bed days and over $1 billion CAD in healthcare spending. The demand for these procedures, both in Canada and internationally, is only expected to increase. Same-day discharge has been demonstrated to be safe and effective in properly selected patients and has the potential to greatly decrease the cost of THA and TKA, collectively referred to as total joint arthroplasty (TJA). The existing literature focuses on implementing outpatient TJA from the physician’s perspective. However, patient opinions do not always align with physician opinions. To date, only one study has explored patients’ perspectives regarding outpatient TJA; many questions remain unanswered. To effectively implement or expand outpatient joint replacement programs, detailed exploration of the patient perspective is necessary. Methods: This study is a multicentre cross-sectional survey to primarily determine the proportion of patients who are open to outpatient TJA. Adult patients scheduled for primary TJA surgery or those who have received TJA surgery in the past year will be included in the survey. The secondary objectives of this survey are to determine patient characteristics associated with openness to outpatient TJA, describe patient concerns regarding outpatient TJA, and identify potential methods to increase patient comfort with outpatient TJA. Discussion: Resource expenditure and clinical practice are increasingly guided by subjective patient outcomes, especially in the area of joint replacement. With the current focus on cost-efficiency in healthcare, there is increasing interest in outpatient TJA. By exploring how patients perceive outpatient TJA, this study may serve to guide the development of educational resources and programs to enhance and support outpatient TJA. Addressing concerns identified by patients in an evidence-based manner has the potential to improve patient satisfaction and outcomes in the growing trend of outpatient TJA.

Background: Total hip arthroplasty (THA) is one of the most common surgical procedures. Although THA surgeries are typically very successful, between 3% and 17% of all patients experience trochanteric pain after surgery. Unfortunately, there remains little high quality and reproducible evidence surrounding this disorder, especially following total hip replacement. The objectives of this review are to describe, among pre-operative or post-operative primary THA patients the prevalence, treatments, prognosis, risk factors, and diagnostic methods available for trochanteric pain. Methods: This is a protocol for a descriptive systematic review of trochanteric pain among THA patients. We will include studies of all study designs, with the exception of non-systematic reviews and expert opinion, with no date limits. We will search Medline, Embase, CINAHL, and the Cochrane Library using the Ovid search interface. We will also search the reference lists of included studies for possible missed studies. We will use the systematic review management software Rayyan to assist with study screening. Two reviewers will independently review studies for inclusion and extract data into a study-specific database. Discussion: This study will add to the literature by comprehensively and systematically evaluating the available literature on trochanteric pain after THA. Previous studies have been conducted on the topic but they were not comprehensive or did not review the literature systematically. Additionally, our study will critically evaluate the methodological quality of the included studies, adding an evidence-based component to the review. This review will help orthopaedic surgeons better care for patients with trochanteric pain after THA, and will identify knowledge gaps for future research. Registration: This protocol will be registered on PROSPERO

Gabapentin was investigated as a single-dose adjunct to morphine for postoperative pain management. The primary objective was to determine if gabapentin given preoperatively and for two days postoperatively as part of multimodal analgesia would decrease postoperative morphine consumption in patients undergoing primary total hip arthroplasty (THA). The study group included 102 patients aged 19-90 years who were undergoing primary THA in a single joint with no contraindications to the study medications, no chronic pain syndrome, and no chronic opioid use. Intervention group patients (n = 48) received gabapentin 600 mg po preoperatively and 200 mg postoperatively on the day of surgery. They were continued on gabapentin at 200 mg three times daily for two days. Control group patients (n = 54) received placebo in a similar fashion. Preoperatively, all patients were given 30 mg of ketorolac intravenously and acetaminophen 1000 mg po. Postoperatively, they received intravenous patient-controlled analgesia with morphine, along with ketorolac 15 mg iv and acetaminophen 1000 mg po every six hours. The primary outcome was mean (SD) postoperative morphine consumption at 72 hr which was 55.8 (39.2) mg in the gabapentin groups vs 60.7 (37.2) mg for the control group (mean difference, −4.91 mg, 95% confidence intervals [CI]: −21.2 to 11.35; P = 0.550). There were no significant differences between the groups regarding secondary outcomes: pain scores, side effects, range of motion. Patient satisfaction on day 3 was more favourable in the placebo group. Length of hospitalization was marginally shorter in the placebo group. This trial indicated that gabapentin treatment had no clinically important reduction in postoperative morphine consumption at 72 hr in patients undergoing THA. Multimodal analgesia may account for the similar primary and secondary outcomes found in the groups. This trial was registered at ClinicalTrials.gov, number: NCT01307202.

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

article i nfo Introduction: Variability in platelet response to aspirin has been reported in patients undergoing cardiac sur- gery but has rarely been described in other operative settings and its mechanism remains uncertain. We per- formed a prospective cohort study to investigate the variability in platelet response to aspirin and to explore its mechanism in patients undergoing major orthopedic surgery. Materials and Methods: Twelve aspirin-treated patients undergoing elective hip or knee replacement were recruited. Once-daily aspirin was continued throughout the perioperative period. We measured platelet function using light transmission aggregation (LTA) in response to arachidonic acid (PLAA) and serum throm- boxane B2 (TXB2) at baseline (before surgery) as well as on days 1, 2, 3, 4, 5, 6, and 8 after surgery. We defined aspirin low response as a PLAA>20%. Results: Six patients exhibited aspirin low response, which typically started on post-operative days 3 or 4; the remaining 6 patients had normal response to aspirin. Compared to aspirin responders, patients with aspirin low response showed significantly higher serum TXB2 levels, a more pronounced early decrease in platelet count, and a significantly more rapid recovery of the platelet count after surgery. Conclusion: Aspirin response variability occurred in patients after major orthopedic surgery, with one-half of the patients in our study exhibiting post-operative aspirin low response. Increased platelet turnover might be a contributor to aspirin response variability after orthopedic surgery.

Background: Guidelines exist for the surgical treatment of hip fracture, but the effect of early surgery on mortality and other outcomes that are important for patients remains unclear. We conducted a systematic review and meta-analysis to determine the effect of early surgery on the risk of death and common postoperative complications among elderly patients with hip fracture. Methods: We searched electronic databases (including MEDLINE and EMBASE), the archives of meetings of orthopedic associations and the bibliographies of relevant articles and questioned experts to identify prospective studies, published in any language, that evaluated the effects of early surgery in patients undergoing procedures for hip fracture. Two reviewers independently assessed methodologic quality and extracted relevant data. We pooled data by means of the DerSimonian and Laird random-effects model, which is based on the inverse variance method. Results: We identified 1939 citations, of which 16 observational studies met our inclusion criteria. These studies had a total of 13 478 patients for whom mortality data were complete (1764 total deaths). Based on the five studies that reported adjusted risk of death (4208 patients, 721 deaths), irrespective of the cut-off for delay (24, 48 or 72 hours), earlier surgery (i.e., within the cut-off time) was associated with a significant reduction in mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68–0.96, p = 0.01). Unadjusted data indicated that earlier surgery also reduced in-hospital pneumonia (RR 0.59, 95% CI 0.37–0.93, p = 0.02) and pressure sores (RR 0.48, 95% CI 0.34–0.69, p Interpretation: Earlier surgery was associated with a lower risk of death and lower rates of postoperative pneumonia and pressure sores among elderly patients with hip fracture. These results suggest that reducing delays may reduce mortality and complications.

Giangregorio LM, Thabane L, deBeer J, Farrauto L, McCartney N, Adachi JD, Papaioannou A. Body weight–supported treadmill training for patients with hip fracture: a feasibility study. Objective To determine the feasibility of body weight–supported treadmill training (BWSTT) as a strategy for improving independent ambulation among patients who had sustained a hip fracture. Design Nonrandomized controlled trial. Setting Inpatient rehabilitation. Participants Patients with a stable hip fracture and at least 50% weight-bearing. Intervention BWSTT in lieu of standard walking exercises throughout stay in rehabilitation. Main Outcomes Measures Feasibility outcomes included the number of patients agreeing to participate in treadmill walking, the number who returned for follow-up assessments, compliance, and the number of adverse events. Secondary outcomes included the Lower Extremity Functional Scale, the Timed Up & Go test, a 2-minute walk test, and the Falls Self-Efficacy Scale. Univariate regression was used to assess the group effect on score changes from baseline to discharge and from baseline to follow-up. Results Among 41 potentially eligible patients, 21 (51%) agreed to participate and 14 returned for follow-up assessments. The recruitment goal of 12 patients agreeing to BWSTT was achieved; however, retention by 3-month follow-up was 67%. The average compliance was 3 sessions a week; however, several patients were below average. No adverse events of BWSTT were reported. There were no significant differences between groups with respect to secondary outcomes. Conclusions BWSTT may be a feasible method for retraining gait among patients with hip fracture. However, future studies evaluating its efficacy need rigorous methods for ensuring compliance and retention.

Objective: To compare the amount of non-enzymatic and enzymatic collagen crosslinks in bone specimens from total hip replacement patients with and without type 2 diabetes (controls). Methods: This ex vivo cross-sectional study included 34 bone specimens (13 from patients with type 2 diabetes, 21 from controls) from men and women ≥ 65 years. All participants were undergoing an elective total hip replacement due to osteoarthritis. Cancellers cores were extracted from the interior of the femoral neck/head and bone cores were reduced to approximately 50 mg of powder. High performance liquid chromatography (HPLC) was used to quantify pentosidine, pyridinoline (PYD) and deoxypyridoline (DPD), which were normalized to collagen content. The mean (SD) was calculated for continuous variables and an independent Student’s t-test was used to compare crosslink content between groups. Results: 13 specimens were collected from participants with type 2 diabetes (mean [SD] age 73.8 [6.2] years) and 21 specimens were collected from controls (mean [SD] age 76.7 [6.8] years, p=0.222). There was no between-group difference in the amount of bone pentosidine (type 2 diabetes: 2.07 [0.94] mmol/mol collagen vs. control: 1.99 [0.60] mmol/mol collagen, p=0.753), PYD (type 2 diabetes: 219.2 [25.3] mmol/mol collagen vs. control: 208.1 [25.8] mmol/mol collagen, p=0.227) or DPD (type 2 diabetes: 132.3 [25.9] mmol/mol collagen vs. control: 130.0 [22.8] mmol/mol collagen, p=0.787). Conclusion: Elective total hip replacement patients with and without type 2 diabetes have similar collagen crosslink profiles. Future studies should consider potential confounding factors, such as bone turnover rate, which may influence collagen crosslink content.

Shiyuan Zhang,1 James Paul,2 Manyat Nantha-Aree,2 Norman Buckley,2 Uswa Shahzad,2 Ji Cheng,2 Justin DeBeer,5 Mitchell Winemaker,5 David Wismer,5 Dinshaw Punthakee,5 Victoria Avram,5 Lehana Thabane1–4 1Department of Clinical Epidemiology and Biostatistics, McMaster University, 2Department of Anesthesia, McMaster University, 3Biostatistics Unit/Centre for Evaluation of Medicines, St Joseph’s Healthcare-Hamilton, 4Population Health Research Institute, Hamilton Health Science/McMaster University, 5Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, ON, Canada Background: Postoperative pain management in total joint replacement surgery remains ineffective in up to 50% of patients and has an overwhelming impact in terms of patient well-being and health care burden. We present here an empirical analysis of two randomized controlled trials assessing whether addition of gabapentin to a multimodal perioperative analgesia regimen can reduce morphine consumption or improve analgesia for patients following total joint arthroplasty (the MOBILE trials). Methods: Morphine consumption, measured for four time periods in patients undergoing total hip or total knee arthroplasty, was analyzed using a linear mixed-effects model to provide a longitudinal estimate of the treatment effect. Repeated-measures analysis of variance and generalized estimating equations were used in a sensitivity analysis to compare the robustness of the methods. Results: There was no statistically significant difference in morphine consumption between the treatment group and a control group (mean effect size estimate 1.0, 95% confidence interval −4.7, 6.7, P=0.73). The results remained robust across different longitudinal methods. Conclusion: The results of the current reanalysis of morphine consumption align with those of the MOBILE trials. Gabapentin did not significantly reduce morphine consumption in patients undergoing major replacement surgeries. The results remain consistent across longitudinal methods. More work in the area of postoperative pain is required to provide adequate management for this patient population. Keywords: postoperative morphine consumption, randomized controlled trials, gabapentin, reanalysis

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated abnormal laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

The purpose of this study was to determine whether trabecular bone mineralization differed in adults with type 2 diabetes compared to adults without type 2 diabetes.Proximal femur specimens were obtained following a total hip replacement procedure from men and women ≥65 years of age with and without type 2 diabetes. A scanning electron microscope was used for quantitative backscattered electron imaging (qBEI) analysis of trabecular bone samples from the femoral neck. Gray scale images (pixel size=5.6 μm(2)) were uploaded to ImageJ software and gray level (GL) values were converted to calcium concentrations (weight [wt] % calcium [Ca]) using data obtained with energy dispersive X-ray spectrometry. The following bone mineralization density distribution (BMDD) outcomes were collected: the weighted mean bone calcium concentration (CaMEAN), the most frequently occurring bone calcium concentration (CaPEAK) and mineralization heterogeneity (CaWIDTH). Differences between groups were assessed using the Student's t-test for normally distributed data and Mann-Whitney U-test for non-normally distributed data. An alpha value of0.05 was considered significant.Thirty-five Caucasian participants were recruited (mean [standard deviation, SD] age, 75.5 [6.5]years): 14 adults with type 2 diabetes (years since type 2 diabetes diagnosis, 13.5 [7.4]years) and 21 adults without type 2 diabetes. In the adults with type 2 diabetes, bone CaMEAN was 4.9% greater (20.36 [0.98]wt.% Ca versus 19.40 [1.07]wt.% Ca, p=0.015) and CaWIDTH was 9.4% lower (median [interquartile range] 3.55 [2.99-4.12]wt.% Ca versus 3.95 [0.71]wt.% Ca, p0.001) compared to controls. There was no between-group difference in CaPEAK (21.12 [0.97]wt.% Ca for type 2 diabetes versus 20.44 [1.30]wt.% Ca for controls, p=0.121).The combination of elevated mean calcium concentration in bone and lower mineralization heterogeneity in adults with type 2 diabetes may have deleterious effects on the biomechanical properties of bone. These microscopic alterations in bone mineralization, which may be mediated by suppressed bone remodeling, further elucidate higher fracture risk in adults with type 2 diabetes.

This study assessed whether gabapentin given preoperatively and for two days postoperatively (in addition to patient-controlled analgesia [PCA] morphine, acetaminophen, and ketorolac) is effective in reducing morphine requirements and moderating pain scores when compared with placebo for primary total knee arthroplasty.This single-centre double-blind randomized controlled trial was undertaken in patients who underwent primary total knee arthroplasty. All subjects received acetaminophen 1,000 mg and ketorolac 15 mg po preoperatively. Postoperatively, subjects received PCA morphine, acetaminophen 1,000 mg every six hours, and ketorolac 15 mg po every six hours. Subjects received either gabapentin 600 mg po preoperatively followed by 200 mg po every eight hours for two days or matching placebo. The primary outcome was cumulative morphine consumption at 72 hr following surgery. Secondary outcome measures included pain scores and patient satisfaction.There were 52 subjects in the gabapentin group and 49 subjects in the placebo group. The average cumulative morphine consumption at 72 hr postoperatively was 66.3 mg in the gabapentin group and 72.5 mg in the placebo group (difference -6.2 mg; 95% confidence interval -29.1 to 16.8 mg; P = 0.59). Mean pain scores at rest, with passive movement, or with weight bearing were similar in both groups at corresponding time periods for the first three days following surgery. In addition, mean patient satisfaction scores and hospital length of stay were similar in the two groups.Gabapentin 600 mg po given preoperatively followed by 200 mg po every eight hours for two days has no effect on postoperative morphine consumption, pain scores, patient satisfaction, or length of hospital stay. This trial is registered at ClinicalTrials.gov NCT01307202.

Objective.Although total knee replacement (TKR) has a high reported success rate, the pain relief and functional improvement after surgery vary. The purpose of our retrospective cohort study was to determine the prevalence of patients showing no clinically important improvement 1 year after TKR, and patient factors that may predict this outcome.Methods.We reviewed primary TKR registry data that were collected from 2 academic hospitals: the Toronto Western Hospital and the Hamilton Health Sciences Henderson Hospital in Ontario, Canada. Relevant covariates including demographic data, body mass index, and comorbidity were recorded. Knee joint pain and functional status were assessed at baseline and at 1-year followup with the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Oxford Knee Score (OKS) to measure the change using the minimal clinically important difference (MCID). Logistic regression modeling was used to identify the predictors of interest.Results.Overall, 11.7% (373/3177) of patients reported no clinically important improvement 1 year after surgery. Logistic regression modeling showed that a greater patient age independently predicted no clinically important improvement on the WOMAC scale 1 year after surgery (p = 0.0003), while being male independently predicted no clinically important improvement on the OKS 1 year after surgery (p = 0.008).Conclusion.Awareness of the prevalence of patients who may show no clinically important improvement and factors that predict this outcome will help patients and surgeons set realistic expectations of surgery.

Background To evaluate osteoporosis knowledge among patients with fractures and to evaluate factors associated with osteoporosis knowledge. Methods Patients with fragility fractures participated in a telephone interview. Participants were asked what they thought osteoporosis was. Unadjusted odds ratios (OR, 95% CI) were calculated to identify factors associated with a correct definition. Predictors identified in univariate analysis were entered into multivariable logistic regression models. A subset also completed the Facts on Osteoporosis Quiz. Results One hundred twenty-seven patients (82% women) participated in the study, with mean (SD) age being 67.5 (12.7) years. Ninety-five (75%) respondents gave correct osteoporosis definitions. The odds of an individual providing a correct definition of osteoporosis were higher for those who reported a diagnosis of osteoporosis or those who reported higher education levels, but the odds decreased with increasing age. A total of 49 (39%) respondents completed the Facts on Osteoporosis Quiz; the average score was 13.6 (3.8) of 21. Areas that respondents scored poorly on were related to key risk factors. Conclusion Many patients with fractures are unaware of important risk factors. Education initiatives aimed at improving osteoporosis knowledge should be directed at individuals at high risk of fracture. Nurses and other allied healthcare providers working in fracture clinics, acute care, and rehabilitation settings are in an ideal position to communicate information about osteoporosis and fracture risk to individuals with a recent fragility fracture.

The role of nuclear factor-erythroid 2 p45-related factor 2 (Nrf2) and Kelch-like ECH-associated protein 1 (Keap1) redox signaling has not been characterized in human skeletal muscle despite an extensive delineation of oxidative stress in the etiology of aging and sarcopenia. We assessed whether the age-associated decline in antioxidant response is due, at least in part, to dysfunction in Nrf2-Keap1 redox signaling. We also evaluated whether an active lifestyle can conserve skeletal muscle cellular redox status via activation of Nrf2-Keap1 signaling. Here we show that a recreationally active lifestyle is associated with the activation of upstream modulators that induce the Nrf2-mediated antioxidant response cascade in skeletal muscle of the elderly. Conversely, a sedentary lifestyle is negatively associated with these adaptations mainly because of dysregulation of Nrf2-Keap1 redox signaling that renders the intracellular environment prone to reactive oxygen species-mediated toxicity. Our results indicate that an active lifestyle is an important determinant of cellular redox status. We propose that the metabolic induction of Nrf2-Keap1 redox signaling promises to be a viable therapy for attenuating oxidative stress-mediated damage in skeletal muscle associated with physical inactivity.

The role of mitochondrial dysfunction and oxidative stress has been extensively characterized in the aetiology of sarcopenia (aging-associated loss of muscle mass) and muscle wasting as a result of muscle disuse. What remains less clear is whether the decline in skeletal muscle mitochondrial oxidative capacity is purely a function of the aging process or if the sedentary lifestyle of older adult subjects has confounded previous reports. The objective of the present study was to investigate if a recreationally active lifestyle in older adults can conserve skeletal muscle strength and functionality, chronic systemic inflammation, mitochondrial biogenesis and oxidative capacity, and cellular antioxidant capacity. To that end, muscle biopsies were taken from the vastus lateralis of young and age-matched recreationally active older and sedentary older men and women (N = 10/group; female symbol = male symbol). We show that a physically active lifestyle is associated with the partial compensatory preservation of mitochondrial biogenesis, and cellular oxidative and antioxidant capacity in skeletal muscle of older adults. Conversely a sedentary lifestyle, associated with osteoarthritis-mediated physical inactivity, is associated with reduced mitochondrial function, dysregulation of cellular redox status and chronic systemic inflammation that renders the skeletal muscle intracellular environment prone to reactive oxygen species-mediated toxicity. We propose that an active lifestyle is an important determinant of quality of life and molecular progression of aging in skeletal muscle of the elderly, and is a viable therapy for attenuating and/or reversing skeletal muscle strength declines and mitochondrial abnormalities associated with aging.

Background To evaluate factors associated with whether patients associate their fracture with future fracture risk. Methods Fragility fracture patients participated in a telephone interview. Unadjusted odds ratios (OR, [95% CI]) were calculated to identify factors associated with whether patients associate their fracture with increased fracture risk or osteoporosis. Predictors identified in univariate analysis were entered into multivariable logistic regression models. Results 127 fragility fracture patients (82% female) participated in the study, mean (SD) age 67.5 (12.7) years. An osteoporosis diagnosis was reported in 56 (44%) participants, but only 17% thought their fracture was related to osteoporosis. Less than 50% perceived themselves at increased risk of fracture. The odds of an individual perceiving themselves at increased risk for fracture were higher for those that reported a diagnosis of osteoporosis (OR 22.91 [95%CI 7.45;70.44], p < 0.001), but the odds decreased with increasing age (0.95 [0.91;0.99], p Conclusion Many fragility fracture patients do not associate their fracture with osteoporosis. It is crucial for physicians to communicate to patients that an osteoporosis diagnosis, increasing age or a fragility fracture increases the risk for future fracture.

Objective To explore the perceptions of patients who have sustained a fragility fracture regarding their future fracture risk and the beliefs underlying their perceptions. Methods Patients with fragility fracture participated in a telephone interview. Quantitative and qualitative methods were used to characterize patient characteristics and perspectives of future fracture risk. Content analysis of qualitative statements was independently performed by three investigators to identify common themes and contrasting statements, and the findings were discussed to ensure consensus. Results Consistent themes were identified among participant responses irrespective of whether they responded “yes”, “no” or “unsure” when asked whether they were at increased fracture risk: (1) patients’ perception of risk was influenced by whether or not they believed they had osteoporosis, which may be altered by interaction with health care providers; (2) patients’ had their own perceptions of their bone health; (3) patients’ attributed their risk to their own actions or “carefulness”; and (4) patients’ had specific beliefs about their fracture and determinants of fracture risk. Conclusion Patients who experience fragility fractures develop perceptions about future fracture risk that are influenced by interactions with health care providers, as well as beliefs about their fracture and beliefs that they can modify their risk. Practice implications Health care providers should discuss strategies for fracture prevention with all patients after fragility fracture to ensure that patients understand that participation in preventative behaviours can modify their risk.

Shiyuan Zhang,1 James Paul,2 Manyat Nantha-Aree,2 Norman Buckley,2 Uswa Shahzad,2 Ji Cheng,2 Justin DeBeer,5 Mitchell Winemaker,5 David Wismer,5 Dinshaw Punthakee,5 Victoria Avram,5 Lehana Thabane1–41Department of Clinical Epidemiology and Biostatistics, 2Department of Anesthesia, McMaster University, Hamilton, ON, Canada; 3Biostatistics Unit/Centre for Evaluation of Medicines, St Joseph's Healthcare - Hamilton, Hamilton, ON, Canada; 4Population Health Research Institute, Hamilton Health Science/McMaster University, 5Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, ON, CanadaBackground: Although seemingly straightforward, the statistical comparison of a continuous variable in a randomized controlled trial that has both a pre- and posttreatment score presents an interesting challenge for trialists. We present here empirical application of four statistical methods (posttreatment scores with analysis of variance, analysis of covariance, change in scores, and percent change in scores), using data from a randomized controlled trial of postoperative pain in patients following total joint arthroplasty (the Morphine COnsumption in Joint Replacement Patients, With and Without GaBapentin Treatment, a RandomIzed ControlLEd Study [MOBILE] trials).Methods: Analysis of covariance (ANCOVA) was used to adjust for baseline measures and to provide an unbiased estimate of the mean group difference of the 1-year postoperative knee flexion scores in knee arthroplasty patients. Robustness tests were done by comparing ANCOVA with three comparative methods: the posttreatment scores, change in scores, and percentage change from baseline.Results: All four methods showed similar direction of effect; however, ANCOVA (-3.9; 95% confidence interval [CI]: -9.5, 1.6; P=0.15) and the posttreatment score (-4.3; 95% CI: -9.8, 1.2; P=0.12) method provided the highest precision of estimate compared with the change score (-3.0; 95% CI: -9.9, 3.8; P=0.38) and percent change (–0.019; 95% CI: -0.087, 0.050; P=0.58).Conclusion: ANCOVA, through both simulation and empirical studies, provides the best statistical estimation for analyzing continuous outcomes requiring covariate adjustment. Our empirical findings support the use of ANCOVA as an optimal method in both design and analysis of trials with a continuous primary outcome.Keywords: ANOVA, ANCOVA, change score, knee arthroplastyA Letter to the Editor has been received and published for this article.

We encountered a case of apparent progressive femoral osteolysis around a well-fixed cementless implant in a young patient. At the time of revision arthroplasty, massive hemorrhaging occurred during exposure and attempted femoral component extraction. Urgent packing of the exposed endosteum with polymethyl methacrylate controlled the bone bleeding. Emergent angiography confirmed an arteriovenous malformation with extensive proximal diaphyseal involvement directly at the site of osteolysis. This arteriovenous malformation was treated successfully with selective arterial embolization and second-stage resection. In retrospect, the index arthroplasty operative note indicated an excessive amount of blood loss, and prerevision radiographs showed osteolysis with uncharacteristic vascular markings. The presence of an osteolytic lesion in total hip arthroplasty should not be assumed to be attributed to polyethylene granuloma, and any atypical radiographic features should prompt further preoperative investigations.

Labuda A, Papaioannou A, Pritchard J, Kennedy C, DeBeer J, Adachi JD. Prevalence of osteoporosis in osteoarthritic patients undergoing total hip or total knee arthroplasty. Objective To determine the prevalence of osteoporosis in osteoarthritic patients undergoing total hip or total knee arthroplasty. Design Cross-sectional study. Setting The Specialized Outpatient Rehabilitation Service's (SORS) Pre-surgical Arthroplasty Service located at the Chedoke Hospital, Hamilton Health Sciences, Hamilton, ON, Canada. Participants SORS outpatients (N=364), from the period of March 2006 to March 2007. Interventions Not applicable. Main Outcome Measures Prevalence of osteoporosis was determined by review of a self-reported survey, and defined by (1) self-reported diagnosis of osteoporosis, (2) history of fragility fracture (defined by a bone fracture occuring as a result of a fall from standing height or less after the age of 50), or (3) current treatment for osteoporosis using bisphosphonates. Results Of the study cohort, 26% were classified as having osteoporosis, according to our criteria. Of the patients with self-reported osteoporosis or a history of fragility fractures, only 37% and 17% reported current treatment with bisphosphonates, respectively. Conclusions Osteoporosis is common in the osteoarthritic arthroplasty population, with a prevalence at least equal to that in the general population. Due to the self-reported nature of the study, the prevalence of osteoporosis in this population is likely significantly higher. Results from this study indicate need for further research, specifically in formal assessment for osteoporosis in patients undergoing a joint replacement.

Background There remains uncertainty regarding the appropriate therapeutic management of hip fracture patients. The primary aim of our study was to examine whether large loading doses in addition to daily vitamin D offered any advantage over a simple daily low-dose vitamin D regimen for increasing vitamin D levels. Methods In this randomized controlled study, patients over age 50 with an acute fragility hip fracture were enrolled from two hospital sites in Ontario, Canada. Participants were randomized to one of three loading dose groups: placebo; 50,000 IU vitamin D2; or 100,000 IU D2. Following a placebo/loading dose, all patients received a daily tablet of 1,000 IU vitamin D3 for 90 days. Serum 25-hydroxy vitamin D (25-OHD) was measured at baseline, discharge from acute care (approximately 4-weeks), and 3-months. Results Sixty-five patients were enrolled in the study (44% male). An immediate rise in 25-OHD occurred in the 100,000 group, however there were no significant differences in 25-OHD between the placebo, 50,000 and 100,000 loading dose groups after 4-weeks (69.3, 84.5, 75.6 nmol/L, p = 0.15) and 3-months (86.7, 84.2, 73.3 nmol/L, p = 0.09), respectively. At the end of the study, approximately 75% of the placebo and 50,000 groups had reached the target therapeutic range (75 nmol/L), and 44% of the 100,000 group. Conclusions In correcting vitamin D insufficiency/deficiency in elderly patients with hip fracture, our findings suggest that starting with a lower daily dose of Vitamin D3 achieved similar results as providing an additional large loading dose of Vitamin D2. At the end of the study, all three groups were equally effective in attaining improvement in 25-OHD levels. Given that a daily dose of 1,000 IU vitamin D3 (with or without a loading dose) resulted in at least 25% of patients having suboptimal vitamin D status, patients with acute hip fracture may benefit from a higher daily dose of vitamin D. Trial registration Clinical Trials # NCT00424619