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1.  Trends in reporting of mechanisms and incidence of hip injuries in males playing minor ice hockey in Canada: a cross-sectional study 
There has been a noted increase in the diagnosis and reporting of sporting hip injuries and conditions in the medical literature but reporting at the minor hockey level is unknown. The purpose of this study is to investigate the trend of reporting hip injuries in amateur ice hockey players in Canada with a focus on injury type and mechanism.
A retrospective review of the Hockey Canada insurance database was performed and data on ice hockey hip injuries reported between January 2005 and June 2011 were collected. The study population included all male hockey players from Peewee (aged 11–12 years) to Senior (aged 20+ years) participating in amateur level competition sanctioned by Hockey Canada. Reported cases of ice hockey hip injuries were analyzed according to age, mechanism of injury, and injury subtype. Annual injury reporting rates were determined and using a linear regression analysis trended to determine the change in ice hockey hip injury reporting rate over time.
One hundred and six cases of ice hockey-related hip injuries were reported in total. The majority of injuries (75.5%) occurred in players aged 15–20 years playing at the Junior level. Most injuries were caused by a noncontact mechanism (40.6%) and strains were the most common subtype (50.0%). From 2005 to 2010, the number of reported hip injuries increased by 5.31 cases per year and the rate of reported hip injury per 1,000 registered players increased by 0.02 cases annually.
Reporting of hip injuries in amateur ice hockey players is increasing. A more accurate injury reporting system is critical for future epidemiologic studies to accurately document the rate and mechanism of hip injury in amateur ice hockey players.
PMCID: PMC4069148  PMID: 24966705
amateur ice hockey; hip injury; pelvic injury; mechanism
2.  Trial to re-evaluate ultrasound in the treatment of tibial fractures (TRUST): a multicenter randomized pilot study 
Trials  2014;15:206.
The role of low-intensity pulsed ultrasound (LIPUS) in the management of fractures remains controversial. The purpose of this study was to assess the feasibility of a definitive trial to determine the effect of LIPUS on functional and clinical outcomes in tibial fractures managed operatively.
We conducted a multicenter, concealed, blinded randomized trial of 51 skeletally mature adults with operatively managed tibial fractures who were treated with either LIPUS or a sham device. All participating centers were located in Canada and site investigators were orthopedic surgeons specializing in trauma surgery. The goals of our pilot study were to determine recruitment rates in individual centers, investigators’ ability to adhere to study protocol and data collection procedures, our ability to achieve close to 100% follow-up rates, and the degree to which patients were compliant with treatment. Patients were followed for one year and a committee (blinded to allocation) adjudicated all outcomes. The committee adjudicators were experienced (10 or more years in practice) orthopedic surgeons with formal research training, specializing in trauma surgery.
Our overall rate of recruitment was approximately 0.8 patients per center per month and site investigators successfully adhered to the study protocol and procedures. Our rate of follow-up at one year was 84%. Patient compliance, measured by an internal timer in the study devices, revealed that 39 (76%) of the patients were fully compliant and 12 (24%) demonstrated a greater than 50% compliance. Based on patient feedback regarding excessive questionnaire burden, we conducted an analysis using data from another tibial fracture trial that revealed the Short Musculoskeletal Function Assessment (SMFA) dysfunction index offered no important advantages over the SF-36 Physical Component Summary (PCS) score. No device-related adverse events were reported.
Our pilot study identified key issues that might have rendered a definitive trial unfeasible. By modifying our protocol to address these challenges we have enhanced the feasibility of a definitive trial to explore the effect of LIPUS on tibial fracture healing.
Trial registration
The TRUST definitive trial was registered at on 21 April 2008 (identifier: NCT00667849).
PMCID: PMC4060850  PMID: 24898987
Ultrasound; Fracture healing; Randomized controlled trial
3.  Low-intensity pulsed ultrasonography versus electrical stimulation for fracture healing: a systematic review and network meta-analysis 
Canadian Journal of Surgery  2014;57(3):E105-E118.
To best inform evidence-based patient care, it is often desirable to compare competing therapies. We performed a network meta-analysis to indirectly compare low intensity pulsed ultrasonography (LIPUS) with electrical stimulation (ESTIM) for fracture healing.
We searched the reference lists of recent reviews evaluating LIPUS and ESTIM that included studies published up to 2011 from 4 electronic databases. We updated the searches of all electronic databases up to April 2012. Eligible trials were those that included patients with a fresh fracture or an existing delayed union or nonunion who were randomized to LIPUS or ESTIM as well as a control group. Two pairs of reviewers, independently and in duplicate, screened titles and abstracts, reviewed the full text of potentially eligible articles, extracted data and assessed study quality. We used standard and network meta-analytic techniques to synthesize the data.
Of the 27 eligible trials, 15 provided data for our analyses. In patients with a fresh fracture, there was a suggested benefit of LIPUS at 6 months (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.97–1.41). In patients with an existing nonunion or delayed union, ESTIM had a suggested benefit over standard care on union rates at 3 months (RR 2.05, 95% CI 0.99–4.24). We found very low-quality evidence suggesting a potential benefit of LIPUS versus ESTIM in improving union rates at 6 months (RR 0.76, 95% CI 0.58–1.01) in fresh fracture populations.
To support our findings direct comparative trials with safeguards against bias assessing outcomes important to patients, such as functional recovery, are required.
PMCID: PMC4035413  PMID: 24869616
4.  (Sample) Size Matters! An Examination of Sample Size from the SPRINT Trial 
Journal of orthopaedic trauma  2013;27(4):183-188.
Inadequate sample size and power in randomized trials can result in misleading findings. This study demonstrates the effect of sample size in a large, clinical trial by evaluating the results of the SPRINT (Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial fractures) trial as it progressed.
The SPRINT trial evaluated reamed versus unreamed nailing of the tibia in 1226 patients, as well as in open and closed fracture subgroups (N=400 and N=826, respectively). We analyzed the re-operation rates and relative risk comparing treatment groups at 50, 100 and then increments of 100 patients up to the final sample size. Results at various enrollments were compared to the final SPRINT findings.
In the final analysis, there was a statistically significant decreased risk of re-operation with reamed nails for closed fractures (relative risk reduction 35%). Results for the first 35 patients enrolled suggested reamed nails increased the risk of reoperation in closed fractures by 165%. Only after 543 patients with closed fractures were enrolled did the results reflect the final advantage for reamed nails in this subgroup. Similarly, the trend towards an increased risk of re-operation for open fractures (23%) was not seen until 62 patients with open fractures were enrolled.
Our findings highlight the risk of conducting a trial with insufficient sample size and power. Such studies are not only at risk of missing true effects, but also of giving misleading results.
Level of Evidence
PMCID: PMC3510324  PMID: 23525086
5.  Orthopaedic Surgeons’ Knowledge and Misconceptions in the Identification of Intimate Partner Violence Against Women 
Intimate partner violence (IPV)—physical, sexual, psychologic, or financial abuse between intimate partners—is the most common cause of nonfatal injury to women in North America. As many IPV-related injuries are musculoskeletal, orthopaedic surgeons are well positioned to identify and assist these patients. However, data are lacking regarding surgeons’ knowledge of the prevalence of IPV in orthopaedic practices, surgeons’ screening and management methods, and surgeons’ perceptions about IPV.
We aimed to identify (1) surgeon attitudes and beliefs regarding victims of IPV and batterers and (2) perceptions of surgeons regarding their role in identifying and assisting victims of IPV.
We surveyed 690 surgeon members of the Orthopaedic Trauma Association. The survey had three sections: (1) general perception of orthopaedic surgeons regarding IPV; (2) perceptions of orthopaedic surgeons regarding victims and batterers; and (3) orthopaedic relevance of IPV. One hundred fifty-three surgeons responded (22%).
Respondents manifested key misconceptions: (1) victims must be getting something out of the abusive relationships (16%); (2) some women have personalities that cause the abuse (20%); and (3) the battering would stop if the batterer quit abusing alcohol (40%). In the past year, approximately ½ the respondents (51%) acknowledged identifying a victim of IPV; however, only 4% of respondents currently screen injured female patients for IPV. Surgeons expressed concerns regarding lack of knowledge in the management of abused women (30%).
Orthopaedic surgeons had several misconceptions about victims of IPV and batterers. Targeted educational programs on IPV are needed for surgeons routinely caring for injured women.
PMCID: PMC3585999  PMID: 23283672
6.  Emotional intelligence in orthopedic surgery residents 
Canadian Journal of Surgery  2014;57(2):89-93.
Emotional intelligence (EI) is the ability to understand and manage emotions in oneself and others. It was originally popularized in the business literature as a key attribute for success that was distinct from cognitive intelligence. Increasing focus is being placed on EI in medicine to improve clinical and academic performance. Despite the proposed benefits, to our knowledge, there have been no previous studies on the role of EI in orthopedic surgery. We evaluated baseline data on EI in a cohort of orthopedic surgery residents.
We asked all orthopedic surgery residents at a single institution to complete an electronic version of the Mayer–Salovey–Caruso Emotional Intelligence Test (MSCEIT). We used completed questionnaires to calculate total EI scores and 4 branch scores. Data were analyzed according to a priori cutoff values to determine the proportion of residents who were considered competent on the test. Data were also analyzed for possible associations with age, sex, race and level of training.
Thirty-nine residents (100%) completed the MSCEIT. The mean total EI score was 86 (maximum score 145). Only 4 (10%) respondents demonstrated competence in EI. Junior residents (p = 0.026), Caucasian residents (p = 0.009) and those younger than 30 years (p = 0.008) had significantly higher EI scores.
Our findings suggest that orthopedic residents score low on EI based on the MSCEIT. Optimizing resident competency in noncognitive skills may be enhanced by dedicated EI education, training and testing.
PMCID: PMC3968198  PMID: 24666445
7.  The effect of patient position during trauma surgery on fat embolism syndrome: An experimental study 
Indian Journal of Orthopaedics  2014;48(2):203-210.
The aim of this study was to compare the effect of supine versus lateral position on clinical signs of fat embolism during orthopedic trauma surgery. Dogs served as the current study model, which could be extended and/or serve as a basis for future in vivo studies on humans. It was hypothesized that there would be an effect of position on clinical signs of fat embolism syndrome in a dog model.
Materials and Methods:
12 dogs were assigned to supine (n = 6) and lateral (n = 6) position groups. Airway pressures, heart rate, blood pressure, cardiac output, pulmonary artery pressure, pulmonary artery wedge pressure, right atrial pressure, arterial and venous blood gases, white blood count, platelet count and neutrophil count were obtained. Dogs were then subjected to pulmonary contusion in three areas of one lung. Fat embolism was generated by reaming one femur and tibia, followed by pressurization of the canal.
No difference was found in any parameters measured between supine and lateral positions at any time (0.126 < P < 0.856).
The position of trauma patients undergoing reamed intramedullary nailing did not alter the presentation of the features of the lung secondary to fat embolism.
PMCID: PMC3977378  PMID: 24741144
Canine; fat embolism syndrome; position; trauma surgery
8.  Simultaneous Versus Staged Bilateral Total Knee Arthroplasty 
HSS Journal  2013;9(1):50-59.
An important source of debate in many orthopaedic practices is the choice of performing simultaneous or staged bilateral total knee arthroplasty.
The objective of this meta-analysis is to compare simultaneous bilateral with staged bilateral total knee arthroplasty for peri-operative complication rates, infection rates and mortality outcomes.
All relevant citations were retrieved from MEDLINE, EMBASE, COCHRANE databases and the unpublished literature. Included studies were assessed for methodological quality and abstracted data was conducted independently by two reviewers. Data was categorized into subgroups and pooled using the DerSimonian and Laird’s random effects model.
A total of 18 articles were identified from 873 potentially relevant titles and selected for inclusion in the primary meta-analyses. The incidence of mortality was significantly higher in the simultaneous group at 30 days (RR [relative risk] 3.67, 95% confidence interval [CI] 1.68–8.02, p = 0.001, I2 = 59%, n = 67,691 patients), 3 months (RR 2.45, 95% CI 2.15–2.79, p < 0.00001, I2 = 0%, n = 66,142 patients) and 1 year (RR 1.85, 95% CI 1.66–2.06, p < 0.001, I2 = 0%, n = 65,322 patients) after surgery. However, there were no significant differences between the two groups in regards to in-hospital mortality rates (R 1.18, 95% CI 0.74–1.88, p = 0.48, I2 = 0%, n = 33,814 patients). In addition, there was no increased risk of deep vein thrombosis, cardiac complication, and pulmonary embolism or infection rates in either comparison group.
The results of the analysis suggest that simultaneous bilateral total knee arthroplasty has a significantly higher rate of mortality at 30 days, 3 months and 1 year after surgery, but similar infection and complication rates in comparison to staged bilateral total knee arthroplasty.
PMCID: PMC3640720  PMID: 24426845
simultaneous or staged bilateral; total knee arthroplasty; meta-analysis; complication rates; infection; mortality
9.  Similar mortality rates in hip fracture patients over the past 31 years 
Acta Orthopaedica  2014;85(1):54-59.
Over 320,000 hip fractures occur in North America each year and they are associated with a mortality rate ranging from 14% to 36% within 1 year of surgery. We assessed whether mortality and reoperation rates have improved in hip fracture patients over the past 31 years.
3 electronic databases were searched for randomized controlled trials on hip fracture management, published between 1950 and 2013. Articles that assessed the surgical treatment of intertrochanteric or femoral neck fractures and measured mortality and/or reoperation rates were obtained. We analyzed overall mortality and reoperation rates, as well as mortality rates by fracture type, comparing mean values in different decades. Our primary outcome was the change in 1-year postoperative mortality.
70 trials published between 1981 and 2012 were included in the review. Overall, the mean 1-year mortality rate changed from 24% in the 1980s to 23% in the 1990s, and to 21% after 1999 (p = 0.7). 1-year mean mortality rates for intertrochanteric fractures diminished from 34% to 23% in studies published before 2000 and after 1999 (p = 0.005). Mean mortality rates for femoral neck fractures were similar over time (∼20%). Reoperation rates were also similar over time.
We found similar mortality and reoperation rates in surgically treated hip fracture patients over time, with the exception of decreasing mortality rates in patients with intertrochanteric fractures.
PMCID: PMC3940992  PMID: 24397744
10.  Complications following hip arthroscopy: a retrospective review of the McMaster experience (2009–2012) 
Canadian Journal of Surgery  2013;56(6):422-426.
The use of hip arthroscopy has been steadily rising as technology, experience and surgical education continue to advance. Previous reports of the complication rate associated with hip arthroscopy have varied. The purpose of this study was to report our experience with hip arthroscopy complications at a single Canadian institution (McMaster University).
We performed a retrospective chart review of 2 hip arthroscopists at the same institution to identify patients who had undergone the index surgery and had been followed for a minimum of 6 months postoperatively. We used a standard data entry form to collect information on patient demographic and clinical characteristics, including age, sex, surgical indication and type of complication if any.
A total of 211 patients underwent 236 hip arthroscopies. The mean age at time of surgery was 37 ± 13 years and mean follow-up was 394 ± 216.5 days. The overall complication rate associated with hip arthroscopy was 4.2% (95% confidence interval 2.3%–7.6%). We identified 4 major and 6 minor complications.
Overall, hip arthroscopy appears to be safe, with minor complications occurring more frequently than major ones. However, surgeons should recognize the possibility of serious complications associated with this procedure. Future research should focus on prospective designs looking for potential prognostic factors associated with hip arthroscopy complications.
PMCID: PMC3859786  PMID: 24284151
11.  Development and preliminary validation of a Function IndeX for Trauma (FIX-IT) 
Canadian Journal of Surgery  2013;56(5):E114-E120.
Assessing fracture healing in clinical trials is subjective. The new Function IndeX for Trauma (FIX-IT) score provides a simple, standardized approach to assess weight-bearing and pain in patients with lower extremity fractures. We conducted an initial validation of the FIX-IT score.
We conducted a cross-sectional study involving 50 patients with lower extremity fractures across different stages of healing to evaluate the reliability and preliminary validity of the FIX-IT score. Patients were independently examined by 2 orthopedic surgeons, 1 orthopedic fellow, 2 orthopedic residents and 2 research coordinators. Patients also completed the Short Form-36 version 2 (SF-36v2) questionnaire, and convergent validity was tested with the SF-36v2.
For interrater reliability, the intraclass correlation coefficents ranged from 0.637 to 0.915. The overall interrater reliability for the total FIX-IT score was 0.879 (95% confidence interval 0.828–0.921). The correlations between the FIX-IT score and the SF-36 ranged from 0.682 to 0.770 for the physical component summary score, from 0.681 to 0.758 for the physical function subscale, and from 0.677 to 0.786 for the role–physical subscale.
The FIX-IT score had high interrater agreement across multiple examiners. Moreover, FIX-IT scores correlate with the physical scores of the SF-36. Although additional research is needed to fully validate FIX-IT, our results suggest the potential for FIX-IT to be a reliable adjunctive clinician measure to evaluate healing in lower extremity fractures.
Level of evidence
Diagnostic Study Level I.
PMCID: PMC3788020  PMID: 24067526
12.  Multiple testing in orthopedic literature: a common problem? 
BMC Research Notes  2013;6:374.
Performing multiple tests in primary research is a frequent subject of discussion. This discussion originates from the fact that when multiple tests are performed, it becomes more likely to reject one of the null hypotheses, conditional on that these hypotheses are true and thus commit a type one error. Several correction methods for multiple testing are available. The primary aim of this study was to assess the quantity of articles published in two highly esteemed orthopedic journals in which multiple testing was performed. The secondary aims were to determine in which percentage of these studies a correction was performed and to assess the risk of committing a type one error if no correction was applied.
The 2010 annals of two orthopedic journals (A and B) were systematically hand searched by two independent investigators. All articles on original research in which statistics were applied were considered. Eligible publications were reviewed for the use of multiple testing with respect to predetermined criteria.
A total of 763 titles were screened and 127 articles were identified and included in the analysis. A median of 15 statistical inference results were reported per publication in both journal A and B. Correction for multiple testing was performed in 15% of the articles published in journal A and in 6% from journal B. The estimated median risk of obtaining at least one significant result for uncorrected studies was calculated to be 54% for both journals.
This study shows that the risk of false significant findings is considerable and that correcting for multiple testing is only performed in a small percentage of all articles published in the orthopedic literature reviewed.
PMCID: PMC3856470  PMID: 24053281
Type one error; Multiple testing; Bonferroni; Orthopedic literature; Family wise error rate
13.  The effect of regular physical activity on bone mineral density in post-menopausal women aged 75 and over: a retrospective analysis from the Canadian multicentre osteoporosis study 
Physical activity is known to benefit many physiological processes, including bone turnover. There are; however, currently no clinical guidelines regarding the most appropriate type, intensity and duration of activity to prevent bone loss.
To help address this gap in the literature, we performed a retrospective analysis of data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective cohort of 9423 adult patients, to determine the relationship between the amount of regular daily physical activity performed and bone mineral density. A total of 1169 female participants aged 75 and over provided information regarding their daily activity levels, including the amount of time spent each week performing physical activity at varying levels of intensity. Multiple and linear regression analyses were used to determine the effect of increasing amounts of this regular physical activity on bone mineral density.
The results indicate that a step increase in the amount of physical activity performed each day resulted in a positive effect on bone mineral density at the hip, Ward’s triangle, trochanter and femoral neck (B = 0.006 to 0.008, p < 0.05). Possible confounding factors such as the use of anti-resorptive therapy, body mass index and age were included in the analysis and suggested that age had a negative effect on bone density while body mass index had a positive effect. Anti-resorptive therapy provided a protective effect against loss of bone density.
The data indicate that a step increase in the amount of daily activity, using simple, daily performed tasks, can help prevent decreases in post-menopausal bone mineral density.
PMCID: PMC3765292  PMID: 23971674
Osteoporosis; Physical activity; Bone mineral density; Post-menopausal
14.  Correction: Workers’ Compensation Status: Does It Affect Orthopaedic Surgery Outcomes? A Meta-Analysis 
PLoS ONE  2013;8(8):10.1371/annotation/17766d8c-c285-4e20-8cce-b2bed0be7c36.
PMCID: PMC3732360
15.  Physical Therapists in Primary Care Are Interested in High Quality Evidence Regarding Efficacy of Therapeutic Ultrasound for Knee Osteoarthritis: A Provincial Survey 
The Scientific World Journal  2013;2013:348014.
Recent high-level evidence favours therapeutic ultrasound (US) for reducing pain in people with knee osteoarthritis (OA). It is unknown how current practice patterns align with current evidence regarding US efficacy and whether physical therapists perceive a need for further high-level evidence. We conducted a descriptive electronic survey to characterize the beliefs and use of US among physical therapists in Ontario treating people with nonsurgical knee OA. Most of the 123 respondents (81%) reported at least some use of US with 45% using it often or sometimes. The main goal for using US was to reduce pain in the surrounding soft tissue (n = 66) and/or the knee joint (n = 43). Almost half (46%) endorsed the belief that US is likely to be beneficial for clients with nonsurgical knee OA. Most respondents (85%) expressed interest in the results of a randomized controlled trial evaluating the effectiveness of US on pain and physical function. Patterns of use reflect the respondents' belief that US is likely to be beneficial for knee OA pain.
PMCID: PMC3686145  PMID: 23844391
16.  Development and Validation of an Instrument to Predict Functional Recovery in Tibial Fracture Patients: The Somatic Pre-Occupation and Coping (SPOC) Questionnaire 
Journal of Orthopaedic Trauma  2012;26(6):370-378.
To explore the role of patients’ beliefs in their likelihood of recovery from severe physical trauma.
We developed and validated an instrument designed to capture the impact of patients’ beliefs on functional recovery from injury; the Somatic Pre-occupation and Coping (SPOC) questionnaire. At 6-weeks post-surgical fixation, we administered the SPOC questionnaire to 359 consecutive patients with operatively managed tibial shaft fractures. We constructed multivariable regression models to explore the association between SPOC scores and functional outcome at 1-year, as measured by return to work and short form-36 (SF-36) physical component summary (PCS) and mental component summary (MCS) scores.
In our adjusted multivariable regression models that included pre-injury SF-36 scores, SPOC scores at 6-weeks post-surgery accounted for 18% of the variation in SF-36 PCS scores and 18% of SF-36 MCS scores at 1-year. In both models, 6-week SPOC scores were a far more powerful predictor of functional recovery than age, gender, fracture type, smoking status, or the presence of multi-trauma. Our adjusted analysis found that for each 14 point increment in SPOC score at 6-weeks (14 chosen on the basis of half a standard deviation of the mean SPOC score) the odds of returning to work at 1-year decreased by 40% (odds ratio = 0.60; 95% CI = 0.50 to 0.73).
The SPOC questionnaire is a valid measurement of illness beliefs in tibial fracture patients and is highly predictive of their long-term functional recovery. Future research should explore if these results extend to other trauma populations and if modification of unhelpful illness beliefs is feasible and would result in improved functional outcomes.
PMCID: PMC3263327  PMID: 22011635
17.  Characteristics of highly successful orthopedic surgeons: a survey of orthopedic chairs and editors 
Canadian Journal of Surgery  2013;56(3):192-198.
Highly successful orthopedic surgeons are a small group of individuals who exert a large influence on the orthopedic field. However, the characteristics of these leaders have not been well-described or studied.
Orthopedic surgeons who are departmental chairs, journal editors, editorial board members of the Journal of Bone and Joint Surgery (British edition), or current or past presidents of major orthopedic associations were invited to complete a survey designed to provide insight into their motivations, academic backgrounds and accomplishments, emotional and physical health, and job satisfaction.
In all, 152 surgeons completed the questionnaire. We identified several characteristics of highly successful surgeons. Many have contributed prolific numbers of publications and book chapters and obtained considerable funding for research. They were often motivated by a “desire for personal development (interesting challenge, new opportunities),” whereas “relocating to a new institution, financial gain, or lack of alternative candidates” played little to no role in their decisions to take positions of leadership. Most respondents were happy with their specialty choice despite long hours and high levels of stress. Despite challenges to their time, successful orthopedic surgeons made a strong effort to maintain their health; compared with other physicians, they exercise more, are more likely to have a primary care physician and feel better physically.
Departmental chairs, journal editors and presidents of orthopedic associations cope with considerable demands of clinical, administrative, educational and research duties while maintaining a high level of health, happiness and job satisfaction.
PMCID: PMC3672433  PMID: 23706848
18.  Practical Tips for Surgical Research 
Canadian Journal of Surgery  2013;56(3):207-213.
PMCID: PMC3672437  PMID: 23706850
19.  Barriers to and facilitators for screening women for intimate partner violence in surgical fracture clinics: a qualitative descriptive approach 
Intimate Partner Violence (IPV) is a major health issue that involves any physical, sexual or psychological harm inflicted by a current or former partner. Musculoskeletal injuries represent the second most prevalent clinical manifestation of IPV. Health care professionals, however, rarely screen women for IPV. Using qualitative methods, this study aimed to explore the perceived barriers to IPV screening and potential facilitators for overcoming these barriers among orthopaedic surgeons and surgical trainees.
We conducted three focus groups with orthopaedic surgeons, senior surgical trainees, and junior surgical trainees. A semi-structured focus group guide was used to structure the discussions. Transcripts and field notes from the focus groups were analyzed using the qualitative software program N’Vivo (version 10.0; QSR International, Melbourne, Australia). To further inform our focus group findings and discuss policy changes, we conducted interviews with two opinion leaders in the field of orthopaedics. Similar to the focus groups, the interviews were digitally recorded and transcribed, and then analyzed.
In the analysis, four categories of barriers were identified: surgeon perception barriers; perceived patient barriers; fracture clinic barriers and orthopaedic health care professional barriers. Some of the facilitators identified included availability of a crisis team; development of a screening form; presence of IPV posters or buttons in the fracture clinic; and the need for established policy or government support for IPV screening. The interviewees identified the need for: the introduction of evidence-based policy aiming to increase awareness about IPV among health care professionals working within the fracture clinic setting, fostering local and national champions for IPV screening, and the need to generate change on a local level.
There are a number of perceived barriers to screening women in the fracture clinic for IPV, many of which can be addressed through increased education and training, and additional resources in the fracture clinic. Orthopaedic health care professionals are supportive of implementing an IPV screening program in the orthopaedic fracture clinic.
PMCID: PMC3635968  PMID: 23560744
Intimate partner violence (IPV); Musculoskeletal injuries; Barriers; Screening
20.  Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study 
Tibial shaft fractures are the most common long bone fracture and are prone to complications such as nonunion requiring reoperations to promote fracture healing. We aimed to determine the fracture characteristics associated with tibial fracture nonunion, and their predictive value on the need for reoperation. We further aimed to evaluate the predictive value of a previously-developed prognostic index of three fracture characteristics on nonunion and reoperation rate.
We conducted an observational study and developed a risk factor list from previous literature and key informants in the field of orthopaedic surgery, as well as via a sample-to-redundancy strategy. We evaluated 22 potential risk factors for the development of tibial fracture nonunion in 200 tibial fractures. We also evaluated the predictive value of a previously-identified prognostic risk index on secondary intervention and/or reoperation rate. Two individuals independently extracted the data from 200 patient electronic medical records. An independent reviewer assessed the initial x-ray, the post-operative x-ray, and all available sequential x-rays. Regression and chi-square analysis was used to evaluate potential associations.
In our cohort of patients, 37 (18.5%) had a nonunion and 27 (13.5%) underwent a reoperation. Patients with a nonunion were 97 times (95% CI 25.8-366.5) more likely to have a reoperation. Multivariable logistic regression revealed that fractures with less than 25% cortical continuity were predictive of nonunion (odds ratio = 4.72; p = 0.02). Such fractures also accounted for all of the reoperations identified in our sample. Furthermore, our data provided preliminary validation of a previous risk index predictive of reoperation that includes the presence of a fracture gap post-fixation, open fracture, and transverse fracture type as variables, with an aggregate of fracture gap and an open fracture yielding patients with the highest risk of developing a nonunion.
We identified a significant association between degree of cortical continuity and the development of a nonunion and risk for reoperation in tibial shaft fractures. In addition, our study supports the predictive value of a previous prognostic index, which inform discussion of prognosis following operative management of tibial fractures.
PMCID: PMC3614478  PMID: 23517574
Tibial shaft fractures; Reoperation; Secondary intervention; Fracture prognostic index; Fracture characteristics; Nonunion; Cortical continuity
21.  Sources of information influencing decision-making in orthopaedic surgery - an international online survey of 1147 orthopaedic surgeons 
Manufacturers of implants and materials in the field of orthopaedics use significant amounts of funding to produce informational material to influence the decision-making process of orthopaedic surgeons with regards to choice between novel implants and techniques. It remains unclear how far orthopaedic surgeons are really influenced by the materials supplied by companies or whether other, evidence-based publications have a higher impact on their decision-making. The objective was to evaluate the subjective usefulness and usage of different sources of information upon which orthopaedic surgeons base their decisions when acquiring new implants or techniques.
We undertook an online survey of 1174 orthopaedic surgeons worldwide (of whom n = 305 were head of their department). The questionnaire included 34 items. Sequences were randomized to reduce possible bias. Questions were closed or semi-open with single or multiple answers. The usage and relevance of different sources of information when learning about and selecting orthopaedic treatments were evaluated. Orthopaedic surgeons and trainees were targeted, and were only allowed to respond once over a period of two weeks. Baseline information included country of workplace, level of experience and orthopaedic subspecialisation. The results were statistically evaluated.
Independent scientific proof had the highest influence on decisions for treatment while OEM (Original Equipment Manufacturer) driven activities like newsletters, white papers or workshops had the least impact. Comparison of answers from the three best-represented countries in this study (Germany, UK and USA) showed some significant differences: Scientific literature and congresses are significantly more important in the US than in the UK or Germany, although they are very important in all countries.
Independent and peer-reviewed sources of information are preferred by surgeons when choosing between methods and implants. Manufacturers of medical devices in orthopaedics employ a considerable workforce to inform or influence hospital managers and leading doctors with marketing activities. Our results indicate that it might be far more effective to channel at least some of these funds into peer-reviewed research projects, thereby assuring significantly higher acceptance of the related products.
PMCID: PMC3600018  PMID: 23496954
Orthopaedics; Survey; Decision-making process; Evidence-based medicine; Online evaluation; Opinion; Internet-based
22.  Radiographic union score for hip substantially improves agreement between surgeons and radiologists 
Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.
A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.
The agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.
Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.
PMCID: PMC3599458  PMID: 23442540
Hip fractures; Reliability; Fracture healing; Radiographs
23.  Predictors of Seizure Outcomes in Children with Tuberous Sclerosis Complex and Intractable Epilepsy Undergoing Resective Epilepsy Surgery: An Individual Participant Data Meta-Analysis 
PLoS ONE  2013;8(2):e53565.
To perform a systematic review and individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Tuberous Sclerosis Complex undergoing resective epilepsy surgery.
Data Sources
Electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science), archives of major epilepsy and neurosurgery meetings, and bibliographies of relevant articles, with no language or date restrictions.
Study Selection
We included case-control or cohort studies of consecutive participants undergoing resective epilepsy surgery that reported seizure outcomes. We performed title and abstract and full text screening independently and in duplicate. We resolved disagreements through discussion.
Data Extraction
One author performed data extraction which was verified by a second author using predefined data fields including study quality assessment using a risk of bias instrument we developed. We recorded all preoperative factors that may plausibly predict seizure outcomes.
Data Synthesis
To identify predictors of a good seizure outcome (i.e. Engel Class I or II) we used logistic regression adjusting for length of follow-up for each preoperative variable.
Of 9863 citations, 20 articles reporting on 181 participants were eligible. Good seizure outcomes were observed in 126 (69%) participants (Engel Class I: 102(56%); Engel class II: 24(13%)). In univariable analyses, absence of generalized seizure semiology (OR = 3.1, 95%CI = 1.2–8.2, p = 0.022), no or mild developmental delay (OR = 7.3, 95%CI = 2.1–24.7, p = 0.001), unifocal ictal scalp electroencephalographic (EEG) abnormality (OR = 3.2, 95%CI = 1.4–7.6, p = 0.008) and EEG/Magnetic resonance imaging concordance (OR = 4.9, 95%CI = 1.8–13.5, p = 0.002) were associated with a good postoperative seizure outcome.
Small retrospective cohort studies are inherently prone to bias, some of which are overcome using individual participant data. The best available evidence suggests four preoperative factors predictive of good seizure outcomes following resective epilepsy surgery. Large long-term prospective multicenter observational studies are required to further evaluate the risk factors identified in this review.
PMCID: PMC3566144  PMID: 23405072
24.  Intimate partner violence and Musculoskeletal injury: bridging the knowledge gap in Orthopaedic fracture clinics 
Intimate partner violence (IPV) is a serious health issue. There have been widespread research efforts in the area of IPV over the past several decades, primarily focusing on obstetrics, emergency medicine, and primary care settings. Until recently there has been a paucity of research focusing on IPV in surgery, and thus a resultant knowledge gap. Renewed interest in the underlying risk of IPV among women with musculoskeletal injuries has fueled several important studies to determine the nature and scope of this issue in orthopaedic surgery. Our review summarizes the evidence from surgical research in the field of IPV and provides recommendations for developing and evaluating an IPV identification and support program and opportunities for future research.
PMCID: PMC3585708  PMID: 23316813
Intimate partner violence; Domestic violence; Identification program; Orthopaedic surgery; Musculoskeletal injury
25.  Influence of compensation status on time off work after carpal tunnel release and rotator cuff surgery: a meta-analysis 
The assessment of post-surgical outcomes among patients with Workers’ Compensation is challenging as their results are typically worse compared to those who do not receive this compensation. These patients’ time to return to work is a relevant outcome measure as it illustrates the economic and social implications of this phenomenon. In this meta-analysis we aimed to assess the influence of this factor, comparing compensated and non-compensated patients.
Two authors independently searched MEDLINE (Ovid), Embase (Ovid), CINAHL, Google Scholar, LILACS and the Cochrane Library and also searched for references from the retrieved studies. We aimed to find prospective studies that compared carpal tunnel release and elective rotator cuff surgery outcomes for Workers’ Compensation patients versus their non-compensated counterparts. We assessed the studies’ quality using the Guyatt & Busse Risk of Bias Tool. Data collection was performed to depict included studies characteristics and meta-analysis. Three studies were included in the review. Two of these studies assessed the outcomes following carpal tunnel release while the other focused on rotator cuff repair. The results demonstrated that time to return to work was longer for patients that were compensated and that there was a strong association between this outcome and compensation status - Standard Mean Difference, 1.35 (IC 95%; 0.91-1.80, p < 0.001).
This study demonstrated that compensated patients have a longer return to work time following carpal tunnel release and elective rotator cuff surgery, compared to patients who did not receive compensation. Surgeons and health providers should be mindful of this phenomenon when evaluating the prognosis of a surgery for a patient receiving compensation for their condition.
Type of study/level of evidence
Meta-analysis of prospective Studies/ Level III
PMCID: PMC3548717  PMID: 23281638
Workers’ compensation; Hand surgery; Outcomes; Carpal tunnel syndrome; Rotator cuff tears; Systematic review; Time to return to work

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