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Background: Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' Ontario Health Insurance Program (OHIP) billing data over a 2 0-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum. Methods: We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand. Results: A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (p < 0.001). Year of graduation did not have an effect on the first 6 years of billings (p > 0.5). Billings were stable after 6 years in practice (p > 0.09). Conclusion: The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making. Contexte: Le sous-emploi est une r alit pour bon nombre de personnes fra chement dipl m es, qui se tournent vers des postes de suppl ance ou temps partiel faute d'ouvertures. Nous avons voulu analyser les donn es de facturation au R gime d'assurance-maladie de l'Ontario (RAMO) en chirurgie orthop dique sur une p riode de 20 ans comme indicateur indirect des modes de pratique, et avanc l'hypoth se qu'au cours des 6 premi res ann es sur le terrain, la facturation subirait l'effet du sous-emploi et du statut de suppl ant. M thodes: Nous avons analys les facturations annuelles moyennes totales des sp cialistes en chirurgie orthop dique selon l'ann e d'obtention du dipl me, l'ann e de facturation, et le nombre de sp cialistes en chirurgie orthop dique ayant factur pour chacune de ces ann es-l . Nous avons analys les donn es du recensement pour la taille de la population de l'Ontario comme indicateur indirect de la demande en orthop die. R sultats: Selon une analyse transversale de 2019, environ 15 sp cialistes en chirurgie orthop dique par ann e d'obtention du dipl me ont factur en Ontario pour les cohortes de 1995 2016, tandis qu'en 2017 et 2018, ce nombre est pass 30 et 36, respectivement. Le nombre est revenu ce qu'il tait auparavant en 2019 et 2020. Pour les sp cialistes en chirurgie orthop dique qui facturent en Ontario, les tendances de facturation ont t relativement stables, avec une hausse annuelle des facturations moyennes pendant les 6 premi res ann es de pratique (p < 0,001). L'ann e d'obtention du dipl me n'a pas exerc d'effet sur les 6 premi res ann es de facturation (p > 0,5). Les facturations ont t stables apr s 6 ans de pratique (p > 0,09). Conclusion: Le syst me de sant ontarien n'a pas augment le nombre de postes en orthop die malgr l'augmentation et le vieillissement de la population; m me si notre population grandit, le nombre et la r tention des sp cialistes en chirurgie orthop dique n'ont pas suivi le rythme. Il faudra approfondir la recherche pour mieux orienter les d cisions relatives aux effectifs., Establishing a career after training is challenging and stressful for many new surgeons. Challenges may include seeking employment, relocating, and setting up a new practice. Underemployment is a reality for [...]

We sought to compare outcomes and reoperation rates for the surgical treatment of proximal humerus fractures (excluding head-splitting fractures, fracture-dislocations, and isolated greater-tuberosity fractures) in men and women older than 60 years. We searched MEDLINE, Embase, and Cochrane through to Feb. 1, 2022, and included all English-language randomized trials comparing operative versus nonoperative treatment; open reduction and internal fixation (ORIF) with locking plate versus intramedullary nail; arthroplasty versus ORIF; and reverse shoulder arthroplasty versus hemiarthroplasty. Outcomes of interest were functional outcomes (e.g., Constant score), pain outcomes (visual analogue scale scores), and reoperation rates for the interventions of interest when available. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This guideline will benefit patients considering surgical intervention for fractures of the proximal humerus by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. Nous avons cherch comparer les r sultats et les taux de r intervention la suite d'un traitement chirurgical pour une fracture de l'hum rus proximal (excluant les fractures de la t te hum rale, les fractures-luxations et les fractures isol es de la grande tub rosit ) chez les hommes et les femmes g s de plus de 60 ans. Nous avons effectu des recherches dans les bases de donn es MEDLINE, Embase, et Cochrane jusqu'au 1 (er) f vrier 2022 et avons inclus tous les essais randomis s publi s en anglais comparant diff rents duos d'interventions : traitements chirurgicaux ou non chirurgicaux; r ductions ouvertes avec fixation interne (ROFI) r alis es l'aide d'une plaque verrouill e ou enclouages centrom dullaires; arthroplasties ou ROFI; et arthroplasties invers es de l' paule ou h miarthroplasties. Les param tres d'int r t taient la capacit fonctionnelle (p. ex., score de Constant), la douleur (p. ex., chelle analogique visuelle) et le taux de r intervention pour les interventions d'int r t, selon les donn es disponibles. Nous avons valu la qualit des donn es probantes et la solidit des recommandations l'aide de l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Cette ligne directrice profitera aux patients qui envisagent une intervention chirurgicale apr s une fracture de l'hum rus proximal en am liorant les consultations sur les options de traitement chirurgical et les r sultats escompt s. Elle aidera aussi les chirurgiens en am liorant leurs connaissances sur diff rentes approches chirurgicales. Les donn es pr sent es pourraient servir mettre au point des cadres et des outils pour une prise de d cision partag e., Proximal humerus fractures (PHFs) are extremely common, (1) and the incidence is expected to rise significantly as the population ages. (2) Most commonly, PHFs consist of osteoporotic fragility fractures; they [...]

Background: Patients with a tibial shaft fracture experiencing their first postoperative complication following treatment with intramedullary nails may be at greater risk of subsequent complications than the whole population. We aimed to determine whether the initial method of nail insertion influences outcome in patients with a tibial shaft fracture requiring multiple reoperations. Methods: Using the Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures trial data, we categorized patients as those not requiring reoperation, those requiring a single reoperation and those requiring multiple reoperations, and we compared them by nail insertion technique (reamed v. unreamed) and fracture type (open v. closed). We then determined the number of patients whose first reoperation was in response to infection, and we compared other clinical outcomes between the reamed and unreamed groups. Results: Among 1226 patients included in this analysis, 175 (14.27%) experienced a single reoperation and 44 patients (3.59%) underwent multiple reoperations. Nail insertion techniques (reamed v. unreamed) did not play a role in the need to perform multiple reoperations. Seventy-five percent of patients requiring multiple reoperations had open tibial shaft fractures. An equal number of these were reamed and unreamed insertions. The majority of patients had their course complicated by infection and almost 50% of patients whose first reoperation was for infection required more than 2 reoperations for management. The rest required multiple procedures for nonunion or bone loss. Conclusion: Our findings corroborate those of other studies, in which open fracture type rather than nail insertion technique was found to be the cause of morbidity following intramedullary nailing of tibial fractures. Clinical trial registration: www.ClinicalTrials.gov, no. NCT00038129 Contexte : Les cas de fracture de la diaphyse tibiale qui présentent une première complication postopératoire après un enclouage centromédullaire pourraient être exposés à un risque plus grand de complications ultérieures comparativement à la population générale. Nous avons voulu déterminer si la technique initiale d'enclouage a une influence sur les résultats lorsqu'une fracture de la diaphyse tibiale requiert plusieurs réinterventions. Méthodes : À partir de l'essai intitulé Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures pour l'évaluation prospective de l'enclouage alésé des fractures de la diaphyse tibiale, nous avons établi les catégories suivantes : aucune réintervention, 1 seule réintervention et multiples réinterventions, et nous les avons comparées aux plans de la technique d'enclouage (avec c. sans alésage) et du type de fracture (ouverte c. fermée). Nous avons ensuite établi le nombre de cas pour lesquels la première réintervention découlait d'une infection, et nous avons comparé d'autres paramètres cliniques entre les groupes avec et sans alésage. Résultats : Sur les 1226 cas inclus dans cette analyse, 175 (14,27%) ont subi 1 seule réintervention et 44 (3,59%) en ont subi plusieurs. Les techniques d'enclouage (avec c. sans alésage) n'ont joué aucun rôle dans le recours à de multiples réinterventions. Soixante-quinze pour cent des cas soumis à de multiples réinterventions étaient des fractures ouvertes. Parmi ceuxci, il y avait autant d'enclouages alésés que non alésés. Dans la majorité des cas, la complication était une infection et près de 50% dont la première réintervention découlait d'une infection ont eu besoin de 2 réinterventions pour en venir à bout. Dans les autres cas, les multiples interventions étaient justifiées par des fractures non consolidées ou une perte osseuse. Conclusion : Nos observations confirment les conclusions d'autres études selon lesquelles la cause de la morbidité suivant l'enclouage centromédullaire des fractures tibiales est le type de fracture ouverte plutôt que la technique d'enclouage. Enregistrement de l'essai : www.ClinicalTrials.gov, no. NCT00038129, In the management of tibial shaft fractures, postoperative complications, specifically those that result in a reoperation, are a very important outcome to consider. The likelihood of experiencing a postoperative complication [...]

Background: Wait times for many elective orthopedic surgical procedures in Ontario have become unacceptably long and substantially exceed the recommended guidelines. As a consequence, many patients experience chronic pain, disability and other poor health outcomes. The purpose of this study was to test a novel, resource-saving redesign of outpatient operating room (OR) services, based on tiered grouping of surgical cases, to maximize health benefits for patients while improving efficiency and decreasing wait times. Methods: This prospective cohort study enrolled adult patients scheduled to undergo unilateral lower limb procedures that had a low requirement for surgical resources and did not require admission to the hospital (ambulatory surgical services) at an academic hospital. Patients were randomly assigned to a conventional OR group or a high-efficiency (tiered) OR group, in which the intensity of surgical, anesthesia and nursing resources was matched to the procedure and the patient's health status. The tiered OR made use of local anesthesia and a block room rather than general anesthesia. Primary outcomes were costs of surgical services provided and patient health outcomes; secondary outcomes were patient and staff satisfaction with each OR setup. Results: The costs associated with the high-efficiency OR were 60% lower than those associated with the conventional OR (this was primarily due to the streamlining of OR care and elimination of the need to use a postanesthetic care unit), with the same or equivalent patient health outcomes. No differences in patient and staff satisfaction were found between the 2 setups. Conclusion: The use of tiered, ambulatory services for elective orthopedic surgery does not compromise health outcomes and patient satisfaction, and it is associated with substantial cost savings. Contexte : En Ontario, les temps d'attentes de plusieurs interventions en chirurgie orthopédique non urgentes s'allongent déraisonnablement et excèdent large-ment ceux des lignes directrices. Par conséquent, plusieurs patients doivent vivre avec de la douleur chronique, une invalidité ou d'autres problèmes de santé. Le but de cette étude était de mettre à l'essai une nouvelle configuration des services en salle d'opération pour les patients ambulatoires qui permettrait d'économiser les ressources et qui se fonderait sur un regroupement des cas chirurgicaux en échelons afin de maximiser les bienfaits pour la santé des patients tout en améliorant l'efficacité et en diminuant les temps d'attente. Méthodes : Dans cette étude de cohorte prospective, les patients adultes participants ont subi dans un hôpital universitaire une intervention chirurgicale unilaté-rale à un membre inférieur demandant peu de ressources et ne nécessitant pas d'hospitalisation (services de chirurgie ambulatoire). Les patients étaient répartis aléatoirement en 2 groupes : 1 groupe était assigné à une salle d'opération clas-sique, et l'autre à une salle à rendement élevé (interventions échelonnées), où l'intensité des ressources allouées à l'intervention, à l'anesthésie et au personnel infirmier correspondait au type d'intervention et à l'état de santé du patient. La salle d'opération par échelons avait la possibilité d'utiliser l'anesthésie locale dans une salle d'anesthésie locorégionale plutôt qu'une anesthésie générale. Les paramètres principaux de l'étude étaient le coût des services chirurgicaux fournis et les résultats cliniques des patients; le paramètre secondaire était la satisfaction des patients et du personnel de chaque configuration de la salle d'opération. Résultats : Les coûts associés aux salles d'opération à rendement élevé étaient inférieurs de 60% à ceux associés aux salles d'opération classiques (cette différence s'expliquerait par la simplification des soins en salle d'opération et l'élimination du besoin d'une salle de réveil), pour des résultats cliniques similaires ou équivalents. Aucune différence dans la satisfaction des patients et du personnel n'a été observée entre les 2 configurations. Conclusion : Le recours à l'échelonnage des services ambulatoires pour l'exécution des interventions en chirurgie orthopédique non urgentes ne compromet ni les résultats cliniques ni la satisfaction des patients et s'accompagne d'une réduction substan tielle des coûts., In Canada, more than 11% of the country's gross domestic product (GDP) and almost 50% of provincial budgets are spent on health care expenditures, (1) yet the high spending is [...]

Background: The purpose of this study was to evaluate the influence of discharge timing on 30-day complication rates following total hip arthroplasty. Methods: We identified patients who underwent total hip arthroplasty between 2011 and 2017 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Using propensity score matching, we matched patients who were discharged from the hospital on the day of surgery to those discharged on post operative days 1, 2, 3 and 4, respectively. We used multivariable logistic regression to determine if the rates of complications and readmission differed depending on length of stay. Results: We identified 141 594 patients who underwent total hip arthroplasty (average age 64.7 [standard deviation (SD) 11.4] yr) from the NSQIP database. The average length of stay was 2.3 days and decreased from 2.8 (SD 0.7) days in 2011 to 1.9 (0.9) days in 2017. The adjusted odds of a major complication increased by 1.33 (1.09-1.61) and 1.41 (1.05-2.21) for patients discharged on postoperative day 3 and 4, respectively, compared with patients discharged on postoperative day 2. Similarly, the adjusted odds of a minor complication increased by 1.22 (1.03-1.43) and 1.58 (1.11-2.26) for patients discharged on postoperative days 3 and 4, respectively, compared with those discharged on postoperative day 2. We found no difference in the risk of major or minor complications between patients discharged on the day of surgery or post operative day 1 compared with patients discharged on postoperative day 2. We also found that a length of stay of 3 or 4 days increased the risk of readmission (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.03-1.29, and OR 1.18, 95% CI 1.08-1.85, respectively) compared with a length of stay of 2 days. Conclusion: Our data suggest that discharge on postoperative days 0-2 is associated with the lowest risk of 30-day complications following total hip arthroplasty. These findings support early discharge after total hip arthroplasty; however, more prospective clinical data are required to determine the optimal length of stay following total hip arthroplasty. Contexte : Cette etude avait pour but d'evaluer l'incidence du moment du conge hospitalier sur les taux de complication dans les 30 jours suivant une arthroplastie totale de la hanche (ATH). Methodes : Nous avons interroge la base de donnees du National Surgical Quality Improvement Program (NSQIP) du College des chirurgiens des Etats-Unis pour recenser des patients ayant subi une ATH entre 2011 et 2017. Nous avons utilise la methode d'appariement sur score de propension pour comparer des patients ayant recu leur conge le jour de l'intervention a d'autres l'ayant recu 1, 2, 3 et 4 jours apres. Nous nous sommes servis d'une regression logistique multivariee pour determiner si les taux de complications et de readmission differaient selon la duree d'hospitalisation. Resultats : Nous avons repere 141 594 patients ayant subi une ATH dans la base de donnees du NSQIP. L'age moyen etait de 64,7 ans (ecart type [ET] 11,4 ans). La duree moyenne de sejour s'elevait a 2,3 jours et a diminue de 2,8 jours (ET 0,7) en 2011 a 1,9 (ET 0,9) en 2017. Le risque de complications majeures etait plus eleve chez les patients ayant recu leur conge les jours 3 et 4, avec des rapports de cotes (RC) ajustes de 1,33 (1,09-1,61) et de 1,41 (1,05-2,21), par rapport aux patients ayant recu leur conge le jour 2. De meme, le risque de complications mineures a augmente par un facteur de 1,22 (RC 1,03-1,43) pour le jour 3 et de 1,58 (RC 1,11-2,26) pour le jour 4. Nous n'avons releve aucune difference en ce qui a trait au risque de complications majeures ou mineures pour les conges donnes le jour de l'intervention, le lendemain, ou le surlendemain. Nous avons aussi observe que le risque de readmission etait plus eleve pour les sejours de 3 ou 4 jours (RC 1,15, intervalle de confance [IC] de 95 % 1,03-1,29; RC 1,18, IC a 95 %, 1,08-1,85) par rapport a ceux de 2 jours. Conclusion : Ces constatations suggerent une association entre un conge les jours 0-2 suivant une ATH et le risque minimal de complications 30 jours plus tard. Ces resultats appuient un conge precoce suivant l'intervention, mais d'autres donnees cliniques prospectives seront necessaires pour determiner la duree de sejour optimale apres une ATH., Total hip arthroplasty (THA) is one of the most common orthopedic procedures, and it is among the procedures associated with the highest surgical expenditures in some health care systems. Furthermore, [...]

BACKGROUND: Romosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures. METHODS: Patients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed Up & Go (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH). RESULTS: A total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS: Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

BackgroundRomosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures.MethodsPatients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed "Up & Go" (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH).ResultsA total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo.ConclusionsRomosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population.Level of evidenceTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Open fractures are complex presentations with elevated risks of infection and nonunion due to a multitude of factors. Along with early surgical debridement, antibiotics have been heavily utilized and have become part of standard of care to reduce the risks of fracture-related infections. Many aspects of their use have been studied and debated. The early administration of intravenous antibiotics has been shown to significantly reduce the incidence of infection. Furthermore, current standards do not recommend prolonged antibiotic administration post wound closure. Recently, an increasing number of studies have assessed the utility of locally administered antibiotics. Clinical and basic science studies have been relatively supportive of their usage, but further studies are still warranted to further delineate their effects.

Background: Tibial shaft fractures are the most common long-bone injury, with a reported annual incidence of more than 75 000 in the United States. This study aimed to determine whether patients with tibial fractures managed with intramedullary nails experience a lower rate of reoperation if treated at higher-volume hospitals, or by higher-volume or more experienced surgeons. Methods: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) was a multicentre randomized clinical trial comparing reamed and nonreamed intramedullary nailing on rates of reoperation to promote fracture union, treat infection or preserve the limb in patients with open and closed fractures of the tibial shaft. Using data from SPRINT, we quantified centre and surgeon volumes into quintiles. We performed analyses adjusted for type of fracture (open v. closed), type of injury (isolated v. multitrauma), gender and age for the primary outcome of reoperation using multivariable logistic regression. Results: There were no significant differences in the odds of reoperation between high-and low-volume centres (p = 0.9). Overall, surgeon volume significantly affected the odds of reoperation (p = 0.03). The odds of reoperation among patients treated by moderate-volume surgeons were 50% less than those among patients treated by very-low-volume surgeons (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.28-0.88), and the odds of reoperation among patients treated by high-volume surgeons were 47% less than those among patients treated by very-low-volume surgeons (OR 0.53, 95% CI 0.30-0.93). Conclusion: There appears to be no significant additional patient benefit in treatment by a higher-volume centre for intramedullary fixation of tibial shaft fractures. Additional research on the effects of surgical and clinical site volume in tibial shaft fracture management is needed to confirm this finding. The odds of reoperation were higher in patients treated by very-low-volume surgeons; this finding may be used to optimize the results of tibial shaft fracture management. Clinical trial registration: ClinicalTrials.gov, NCT00038129 Contexte: La fracture de la diaphyse tibiale est la plus commune des fractures des os longs, avec une incidence annuelle declaree de plus 75 000 cas aux Etats-Unis. Cette etude visait a determiner si les patients traites par enclouage intra-medullaire pour une fracture du tibia sont moins souvent reoperes quand l'intervention est effectuee dans des etablissements qui traitent de plus forts volumes de cas ou par des chirurgiens operant un plus fort volume de cas ou plus experimentes. Methodes: L'etude SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) est un essai clinique multicentrique randomise qui a compare l'effet de l'enclouage alese c. non alese sur le taux des reinterventions visant a promouvoir la consolidation osseuse de la fracture, a traiter une infection ou a preserver le membre chez des patients victimes de fractures fermees ou ouvertes de la diaphyse tibiale. A partir des donnees de l'etude SPRINT, nous avons classe les etablissements et les chirurgiens en quintiles selon les volumes de cas traites. Nous avons effectue des analyses ajustees en fonction du type de fracture (ouverte c. fermee), du type de blessure (isolee c. polytraumatisme), du sexe et de l'age, pour etablir le taux de reintervention (parametre principal), en utilisant la regression logistique multivariee. Resultats: On n'a note aucune difference significative quant au risque de reinter-vention entre les centres qui traitaient des volumes eleves c. bas (p = 0,9). Dans l'ensemble le volume d'operations des chirurgiens a significativement influe sur le risque de reintervention (p = 0,03). Le risque de reintervention chez les patients traites par des chirurgiens dont le volume d'interventions etait moyen etait de 50 % de moins que chez les patients traites par des chirurgiens dont le volume etait tres bas (risque relatif [RR] 0,50, intervalle de confiance [IC] a 95 % 0,28-0,88) et le risque de reinter-vention chez les patients traites par des chirurgiens dont le volume etait tres eleve etait de 47 % de moins que chez les patients traites par des chirurgiens dont le volume etait tres bas (RR 0,53, IC a 95 % 0,30-0,93). Conclusion: Il ne semble y avoir aucun bienfait additionnel significatif au fait d'etre opere dans un centre ou le volume d'interventions pour enclouage intra-medullaire des fractures de la diaphyse tibiale est eleve. Il faudra approfondir la recherche sur les effets du volume chirurgical et de l'experience clinique des etablissements pour confirmer cette observation. Le risque de reintervention a ete plus eleve chez les patients traites par des chirurgiens dont le volume d'interventions etait tres bas; cette observation pourrait etre utilisee pour optimiser l'issue du traite-ment des fractures de la diaphyse tibiale. Enregistrement de l'essai clinique: ClinicalTrials.gov, NCT00038129., Tibial shaft fractures are the most common long-bone injury, with a reported annual incidence of more than 75 000 in the United States. (1) Treatment aims to achieve union of [...]

Background: The aim of this study was to evaluate the influence of operating time on complications and readmission within 30 days of total knee arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes. Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients 18 years of age and older who underwent TKA between 2006 and 2017, using procedural codes. Patient demographic characteristics, operation length and 30-day major and minor complication and readmission rates were captured. We used multivariable regression to determine if the rates of complications and readmission differed depending on the length of the operation, while adjusting for relevant covariables. Results: A total of 263 174 patients who underwent TKA were identified from the database. Their mean age was 66.8 (standard deviation 9.7) years. Within 30 days of the index procedure, 5700 patients (2.2%) experienced a major complication, 5185 (2.0%) experienced a minor complication and 7730 (3.1% of 249 746 patients from 2011 to 2017) were readmitted. Mean operation length was 91.7 minutes (range 30-240 min). After adjustment for relevant covariables, an operating time of 90 minutes or more was a significant predictor of major and minor complications as well as readmission. There was no difference in the odds of complications or readmission for operations lasting 30-49, 50-69 or 70-89 minutes (p > 0.05). Conclusion: Our data suggest that operating times of 90 minutes or more may be associated with an increase in the 30-day odds of complications and readmission following TKA. Further studies are needed to confirm our findings and determine the influence of surgical time on outcomes when there is increased case complexity. Contexte: Cette étude avait pour but d'évaluer l'influence de la durée opératoire sur les taux de complications et de réadmission dans les 30 jours suivant une arthroplastie totale du genou (ATG) et de déterminer si certaines durées étaient associées à des issues défavorables. Méthodes: Nous avons interrogé la base de données du National Surgical Quality Improvement Program de l'American College of Surgeons pour repérer, à l'aide de codes d'acte, les patients de 18 ans et plus ayant subi une ATG entre 2006 et 2017. Les caractéristiques démographiques des patients, la durée opératoire et les taux de complications mineures et majeures et de réadmission dans les 30 jours suivant l'intervention ont été relevés. Nous nous sommes servis d'une régression logistique multivariée pour déterminer si les taux de complications et de réadmission variaient selon la durée opératoire, tout en tenant compte des covariables pertinentes. Résultats : Au total, 263 174 patients ayant subi une ATG ont été repérés dans la base de données. L'âge moyen était de 66,8 ans (écart type : 9,7 ans). Dans les 30 jours suivant l'intervention de référence, 5700 patients (2,2%) ont présenté une complication majeure et 5185 (2,0%), une complication mineure; 7730 patients (3,1% des 249746 patients ayant subi une ATG entre 2011 et 2017) ont été réhospitalisés. La durée opératoire moyenne était de 91,7 minutes (plage 30-240 minutes). Après la prise en compte des covariables pertinentes, une durée opératoire de 90 minutes ou plus était un facteur prédictif significatif de complications mineures ou majeures et de réadmission. Aucune différence n'a été constatée quant à la probabilité de complications ou de réadmission pour les chirurgies durant de 30-49 minutes, de 50-69 minutes et de 70-89 minutes (p > 0,05). Conclusion : Ces données laissent croire qu'une durée opératoire de 90 minutes ou plus peut être associée à une hausse des taux de complications et de réadmission dans les 30 jours suivant une ATG. D'autres études sont nécessaires pour confirmer ces résultats et déterminer l'influence de la durée opératoire sur les issues des patients au cas complexe., The need for primary total knee arthroplasty (TKA) has grown steadily over the last decade. More than 700 000 TKAs are performed yearly in the United States, and it is [...]

The goal of this article was to review studies on distal humerus fracture plates (DHFPs) to understand the biomechanical influence of systematically changing the plate or screw variables. The problem is that DHFPs are commonly used surgically, although complications can still occur, and it is unclear if implant configurations are always optimized using biomechanical criteria. A systematic search of the PubMed database was conducted to identify English‐language biomechanical optimization studies of DHFPs that parametrically altered plate and/or screw variables to analyze their influence on engineering performance. Intraarticular and extraarticular fracture (EAF) data were separated and organized under commonly used biomechanical outcome metrics. The results identified 52 eligible DHFP studies, which evaluated various plate and screw variables. The most common plate variables evaluated were geometry, hole type, number, and position. Fewer studies assessed screw variables, with number and angle being the most common. However, no studies examined nonmetallic materials for plates or screws, which may be of interest in future research. Also, articles used various combinations of biomechanical outcome metrics, such as interfragmentary fracture motion, bone, plate, or screw stress, number of loading cycles to failure, and overall stiffness (Os) or failure strength (Fs). However, no study evaluated the bone stress under the plate to examine bone "stress shielding," which may impact bone health clinically. Surgeons treating intraarticular and extraarticular distal humerus fractures should seriously consider two precontoured, long, thick, locked, and parallel plates that are secured by long, thick, and plate‐to‐plate screws that are located at staggered levels along the proximal parts of the plates, as well as an extra transfracture plate screw. Also, research engineers could improve new studies by perusing recommendations in future work (e.g., studying alternative nonmetallic materials or "stress shielding"), clinical ramifications (e.g., benefits of locked plates), and study quality (e.g., experimental validation of computational studies). [ABSTRACT FROM AUTHOR]

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50 yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66 yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6 yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66–85 yr, 51.9%–63.9%; ≥86 yr, 34.5%), followed by vertebral fractures in males (66–85 yr, 53.2%–69.4%; ≥86 yr, 35.5%), and hip fractures in females (66–85 yr, 69.8%–79.0%; ≥86 yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86 yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients. [ABSTRACT FROM AUTHOR]