There is little known about how patient socioeconomic status impacts clinical outcomes in hip preservation surgery. The aim of this study was to evaluate the relationship between indices of multiple deprivation, funding provider (NHS Funded or Private Funded) and clinical outcomes following surgery for femoroacetabular impingement (FAI). The study analysed the data of 5590 patients recorded in the NAHR who underwent primary hip arthroscopic treatment for FAI between November 2013 and July 2023. Records were matched to the UK National index of multiple deprivation using the lower layer super output area. Using iHOT12 score, patient reported outcome measures were analysed at base line and 1 year following surgery. 2358 records were matched to LLSOA deciles. Between the lowest (most deprived) 3 deciles and the highest (least deprived) the average baseline iHOT12 score was 28.98 (n=366) and 35.33 (n=821). The proportion of patients receiving treatment through NHS funding compared to independent funding for the most deprived, 292 (90%) 37 (10%) respectively compared to the least deprived 515 (70%) and 244 (30%) respectively. At 1year, iHOT12 scores for each group were 51.64 (29.1 SD) compared to 61.5 (28.06 SD) respectively. The study demonstrates that patients from lower socioeconomic backgrounds had poorer baseline and one-year post-surgery iHOT12 scores compared to those from higher socioeconomic strata. Furthermore, a higher reliance on NHS funding was observed among the most deprived, while more affluent patients predominantly opted for private funding. These findings underscore the significant influence of socioeconomic status on both the quality of healthcare received and recovery outcomes in hip preservation surgery, calling attention to the need for more equitable healthcare solutions

There is limited literature on the effects of socioeconomic factors on outcomes after total ankle arthroplasty (TAA). In the setting of hip or knee arthroplasty, patients of a lower socioeconomic status demonstrate poorer post-operative satisfaction, longer lengths of stay, and larger functional limitations. It is important to ascertain whether this phenomenon is present in ankle arthritis patients. This is the first study to address the weight of potential socioeconomic factors in affecting various socioeconomic classes, in terms of how they benefit from ankle arthroplasty. This is retrospective cohort study of 447 patients who underwent a TAA. Primary outcomes included pre-operative and final follow-up AAOS pain, AAOS disability, and SF-36 scores. We then used postal codes to determine median household income using Canadian 2015 census data. Incomes were divided into five groups based on equal amounts over the range of incomes. This method has been used to study medical conditions such as COPD and cardiac disease. These income groups were then compared for differences in outcome measures. Statistical analysis was done using unpaired t-test. A total of 447 patients were divided into quintiles by income. From lowest income to highest income, the groups had 54, 207, 86, 64, and 36 patients, respectively. The average time from surgery to final follow up was 85.6 months. Interestingly, we found that patients within the middle household income groups had significantly lower AAOS disability scores compared to the lowest income groups at final follow-up (26.41 vs 35.70, p=0.035). Furthermore, there was a trend towards middle income households and lower post-operative AAOS pain scores compared to the lowest income group (19.57 vs 26.65, p=0.063). There was also a trend toward poorer AAOS disability scores when comparing middle income groups to high income groups post-operatively (26.41 vs 32.27, p=0.058). Pre-operatively, patients within the middle-income group had more pain, compared to the lowest and the highest income groups. No significant differences in SF-36 scores were observed. There were no significant differences seen in middle income groups compared to the highest income group for AAOS pain post-operatively. There were no significant differences found in pre-operative AAOS disability score between income groups. Patients from middle income groups who have undergone TAA demonstrate poorer function and possibly more pain, compared to lower and higher income groups. This suggests that TAA is a viable option for lower socioeconomic groups and should not be a source of discouragement for surgeons. In this circumstance there is no real disparity between the rich and the poor. Further investigation is needed to explore reasons for diminished performance in middle class patients

We aimed to identify whether patients in lower socioeconomic groups had worse function prior to total knee arthroplasty and to establish whether these patients had worse post-operative outcome following total knee arthroplasty. Data were obtained from the Kinemax outcome study, a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in thirteen centres, four in the United States, six in the United Kingdom, two in Australia and one in Canada. Pre-operative data were collected within six weeks of surgery and patients were followed for two years post-operatively. Pre-operative details of the patient's demographics, socioeconomic status (education and income), height, weight and co-morbid conditions were obtained. The WOMAC and SF-36 scores were also obtained. Multivariate regression was utilised to analyse the association between socioeconomic status and the patient's pre-operative scores and post-operative outcome. During the analysis, we were able to control for variables that have previously been shown to effect pre-operative scores and post-operative outcome. Patients with a lower income had a significantly worse pre-operative WOMAC pain (p=0.021) and function score (p=0.039) than those with higher incomes. However, income did not have a significant impact on outcome except for WOMAC Pain at 12-months (p=0.014). At all the other post-operative assessment times, there was no correlation between income and WOMAC Pain and WOMAC Function. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. This study demonstrates that across all four countries, patients with lower incomes appear to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to affect the final outcome following total knee arthroplasty. Patients with lower incomes appear able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively

We aimed to identify whether patients in lower socioeconomic groups had worse function prior to total knee arthroplasty and to establish whether these patients had worse post-operative outcome following total knee arthroplasty. Data was obtained from the Kinemax outcome study, this was a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in thirteen centers, four in the United States, six in the United Kingdom, two in Australia and one in Canada. Pre-operative data was collected within six weeks of surgery and patients were followed for two years post-operatively. Pre-operative details of the patient’s demographics, socioeconomic status (education and income), height, weight and co-morbid conditions were obtained. The WOMAC and SF-36 scores were also obtained. Multivariate regression was utilised to analyse the association between socioeconomic status and the patient’s pre-operative scores and post-operative outcome. During the analysis, we were able to control for variables that have previously been shown to effect pre-operative scores and post-operative outcome. Patients with a lower income had a significantly worse pre-operative WOMAC pain (p=0.021) and function score (p=0.039) than those with higher incomes. However, income did not have a significant impact on outcome except for WOMAC Pain at 12-months (p=0.014). At all the other post-operative assessment times, there was no correlation between income and WOMAC Pain and WOMAC Function. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. This study demonstrates that across all four countries, patients with lower incomes appear to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to effect the final outcome following total knee arthroplasty. Patients with lower incomes appear able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively

Introduction

The goal of the current study was to determine if SES affects PROMs in patients treated with THA. Specifically, we sought to determine any potential differences between low and high SES patients in pre-surgical PROMs, post-surgical PROMs, and PROM improvement after surgery while controlling for any potential confounding demographic factors.

Aims. It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital. Methods. We analyzed linked hospital and death records for residents of New South Wales, Australia, aged ≥ 18 years who had an emergency readmission within 90 days following THA or TKA surgery between 2003 and 2022. Multivariable modelling was used to identify factors associated with non-index readmission and to evaluate associations of readmission destination (non-index vs index) with 90-day and one-year mortality. Results. Of 394,248 joint arthroplasty patients (THA = 149,456; TKA = 244,792), 9.5% (n = 37,431) were readmitted within 90 days, and 53.7% of these were admitted to a non-index hospital. Non-index readmission was more prevalent among patients who underwent surgery in private hospitals (60%). Patients who were readmitted for non-orthopaedic conditions (62.8%), were more likely to return to a non-index hospital compared to those readmitted for orthopaedic complications (39.5%). Factors associated with non-index readmission included older age, higher socioeconomic status, private health insurance, and residence in a rural or remote area. Non-index readmission was significantly associated with 90 day (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 1.39 to 2.05) and one-year mortality (aOR 1.31; 95% CI 1.16 to 1.47). Associations between non-index readmission and mortality were similar for patients readmitted with orthopaedic and non-orthopaedic complications (90-day mortality aOR 1.61; 95% CI 0.98 to 2.64, and aOR 1.67; 95% CI 1.35 to 2.06, respectively). Conclusion. Non-index readmission was associated with increased mortality, irrespective of whether the readmission was for orthopaedic complications or other conditions. Cite this article: Bone Jt Open 2024;5(1):60–68

Aims. The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods. This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results. There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion. The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies. Cite this article: Bone Joint J 2024;106-B(1):77–85

Aims. The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods. Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results. The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion. Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients’ health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. Cite this article: Bone Joint J 2024;106-B(4):394–400

INTRODUCTION. Utilization of a patient management support system in our clinical pathway has been successfully demonstrated to both reduce the length of hospital stay after primary THA, as well as reducing the number of hospital readmissions. While successful in a general patient population, the ability of a patient management support system to reduce readmissions in subsets of high risk THA patients has not been evaluated. METHODS. We identified all primary THAs performed at a single institution between 2013 and 2015. Patient sex, age at the time of surgery, race, ASA grade, and 120-day readmissions were retrieved from the patient medical record. Similar to previous studies, the patient's home address was used as a proxy for socioeconomic status, with the estimated median income of a given patient being estimated as the median household income for patients of similar ethnicity living within their zip code as reported in the 2014 U.S. Census. A binary regression was used to determine if a model of patient factors (age, sex, race, socioeconomic status, and/or ASA grade) could accurately predict 120-day readmission after primary THA. Age and socioeconomic status were treated as a continuous variable and all other factors were categorical in nature, and the individual effects of each categorical factor on readmissions were also assessed. RESULTS. A sample of 889 primary THAs was identified using the above criteria, of which 754 (84.8%) were Caucasian and 124 (13.9%) were African Americans. Eleven patients (1.2%) either self-reported a different race or race was unknown. Due to the small number of patients in the other/unknown group, this subset was not included in our analysis. With the remaining sample of 878 THAs (475 females, 403 males; age 62.1 ± 13.0 years), a model containing age, sex, race, socioeconomic status, and ASA grade was unable to accurately predict the need for hospital readmission (R2 = 0.02). When assessed individually, the rates of hospital readmission did not differ by sex or race; however, those with ASA grades I or II had significantly lower readmission rates than patients with ASA grades III or IV (Table 1). DISCUSSION AND CONCLUSION. Despite a comprehensive program, the risk of readmission for patients with greater comorbidity burdens was double that of patients with low ASA grades

Radial head fractures are common and mainly require a functional conservative treatment. About 20% of patients will present an unsatisfactory final functional result. There is, however, little data allowing us to predict which patients are at risk of bad evolve. This makes it difficult to optimize our therapeutic strategies in these patients. The aim of this study is to determine the personal and environmental factors that influence the functional prognosis of patients with a radial head fracture. We realized over a 1-year period a prospective observational longitudinal cohort study including 125 consecutive patients referred for a fracture of the radial head in a tertiary trauma center. We originally collected the factors believed to be prognostic indicators: age, sex, socioeconomic status, factors related to trauma or fracture, alcohol, tobacco, detection of depression scale, and financial compensation. A clinical and radiological follow-up took place at 6 weeks, 3 months, 6 months, and 1 year. The main functional measurement tool is the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH). 123 patients were included in the study. 114 patients required nonsurgical management. 102 patients completed the 1-year follow-up for the main outcome (89 for the DASH score). Two patients required an unplanned surgery and were excluded from analyses. At 1 year, the average MEPS was 96.5 (range, 65–100) and 81% of subjects had an excellent result (MEPS ≥90). The most constant factor to predict an unsatisfactory functional outcome (MEPS <90 or DASH >17) is the presence of depressive symptoms at the initial time of the study (P = 0.03 and P = 0.0009, respectively). This factor is present throughout the follow-up. Other observed factors include a higher socioeconomic status (P = 0.009), the presence of financial compensation (P = 0.027), and a high-velocity trauma (P = 0.04). The severity of the fracture, advanced age, female sex, and the nature of the treatment does not influence the result at 1 year. No factor has been associated with a reduction in range of motion. Most of the radial head fractures heal successfully. We identified for the first time, with a valid tool, the presence of depressive symptoms at the time of the fracture as a significant factor for an unsatisfactory functional result. Early detection is simple and fast and would allow patients at risk to adopt complementary strategies to optimize the result

Introduction. We used patient reported outcome measures (PROMS) to evaluate qualitative and societal outcomes of trauma. Methods. We collected PROMs data between Sept 2013 and March 2015 for 92 patients with injury severity score (ISS) greater than 9. We enquired regarding return to work, income and socioeconomic status, dignity and satisfaction and the EQ-5D questionnaire. Results. Return to work. Of patients working at admission 15/58(26%) anticipated returning to work within 14 days of discharge. Work plans at discharge did not correlate with ISS scores overall (r=−0.05, ns), or when stratified by working group. Increased physicality of work showed a trend towards poorer return to work outcomes (not significant in Spearman's rank analysis: r= 0.14, p= 0.32). Income and socioeconomic status: No significant difference was demonstrated between the comparative incomes of patients with the best and worst return to work outcomes (ANOVA n=61, t=0.63, ns). Lowest quartile earners (n=19) were more likely to complete the open questions (79%) than higher income patients (62%). Dignity and satisfaction: Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. %). Patients ‘mostly’ or ‘always’ satisfied with their care did not have significantly different incomes (ANOVA, t=0.13, ns). EQ-5D: Self-rated health status correlated with perceived likelihood of return to work (r=0.25, p=0.0395). Correlation was demonstrated between EQ-5D scores and perceived dignity preservation (r=0.38, p=0.0004), and overall satisfaction (r=0.46, p< 0.0001). There was no correlation between EQ-5D and ISS score. Conclusion. EQ5D correlated with work plans, dignity, and satisfaction. Planned return to work did not correlate with ISS score or socioeconomic status. Unlike previous studies we demonstrated that lower socioeconomic groups have best engagement with PROMS. This study highlighted the value of qualitative PROMS analysis in leading patient-driven improvements in trauma care

In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort. An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required. A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and axillary nerve injury were also noted at 4.2% each (1/24). Keeping in mind the immense difference in socioeconomical status and patient demographics in a third world country the RSA complication rate in this study correlates with the known international consensus. This also proves that RSA is still a suitable option for rotator cuff arthropathy and glenohumeral osteoarthritis even in an economically constrained environment like South Africa

Abstract. Background. There is a trend towards minimising length of stay (LOS) after total knee arthroplasty (TKA), as longer LOS is associated with poorer outcomes and higher costs. Patient factors known to influence LOS after TKA include age and ASA grade. Evidence regarding body mass index (BMI) in particular is conflicting. Some studies find that increased BMI predicts greater LOS, while others find no such relationship. Previous studies have generally not examined socioeconomic status, which may be a confounder. They have generally been conducted outside the UK, and prior to the Covid-19 pandemic. Methods. We conducted a retrospective cohort study of 1031 primary TKAs performed 01-04-2021 to 31-12-2021, after resumption of elective surgery in our centre. A multivariate regression analysis was performed using a Poisson model over pre-operative variables (BMI, age, gender, ASA grade, index of multiple deprivation, and living arrangement) and peri-operative variables (AM/PM operation, operation side, duration, and day of the week). Results. Mean LOS was 2.6 days. BMI had no effect on LOS (p > 0.05). Longer LOS was experienced by patients of greater age (p < 0.001), increased ASA grade (p < 0.001), living alone (p < 0.01), PM start time (p < 0.001), and longer operation duration (p < 0.01). Male patients had shorter LOS (p < 0.001). Index of multiple deprivation had no effect (p > 0.05). Conclusion. BMI had no effect on LOS after TKA. Being female and living alone are significant risk factors which should be taken in to account in pre-operative planning

Worldwide, most spine imaging is either “inappropriate” or “probably inappropriate”. The Choosing Wisely recommendation is “Do not perform imaging for lower back pain unless red flags are present.” There is currently no detailed breakdown of lower back pain diagnostic imaging performed in New Brunswick (NB) to inform future directions. A registry of spine imaging performed in NB from 2011-2019 inclusive (n=410,000) was transferred to the secure platform of the NB Institute for Data, Training and Research (NB-IRDT). The pseudonymized data included linkable institute identifiers derived from an obfuscated Medicare number, as well as information on type of imaging, location of imaging, and date of imaging. The transferred data did not include the radiology report or the test requisition. We included all lumbar, thoracic, and complete spine images. We excluded imaging related to the cervical spine, surgical or other procedures, out-of-province patients and imaging of patients under 19 years. We verified categories of X-ray, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). Red flags were identified by ICD-10 code-related criteria set out by the Canadian Institute for Health Information. We derived annual age- and sex-standardized rates of spine imaging per 100,000 population and examined regional variations in these rates in NB's two Regional Health Authorities (RHA-A and RHA-B). Age- and sex-standardized rates were derived for individuals with/without red flag conditions and by type of imaging. Healthcare utilization trends were reflected in hospital admissions and physician visits 2 years pre- and post-imaging. Rurality and socioeconomic status were derived using patients’ residences and income quintiles, respectively. Overall spine imaging rates in NB decreased between 2012 and 2019 by about 20% to 7,885 images per 100,000 people per year. This value may be higher than the Canadian average. Females had 23% higher average imaging rate than males. RHA-A had a 45% higher imaging rate than RHA-B. Imaging for red flag conditions accounted for about 20% of all imaging. X-rays imaging accounted for 67% and 75% of all imaging for RHA-A and RHA-B respectively. The proportions were 20% and 8% for CT and 13% and 17% for MRI. Two-year hospitalization rates and rates of physician visits were higher post-imaging. Females had higher age-standardized hospitalization and physician-visit rates, but the magnitude of increase was higher for males. Individuals with red flag conditions were associated with increased physician visits, regardless of the actual reason for the visit. Imaging rates were higher for rural than urban patients by about 26%. Individuals in the lowest income quintiles had higher imaging rates than those in the highest income quintiles. Physicians in RHA-A consistently ordered more images than their counterparts at RHA-B. We linked spine imaging data with population demographic data to look for variations in lumbar spine imaging patterns. In NB, as in other jurisdictions, imaging tests of the spine are occurring in large numbers. We determined that patterns of imaging far exceed the numbers expected for ‘red flag’ situations. Our findings will inform a focused approach in groups of interest. Implementing high value care recommendations pre-imaging ought to replace low-value routine imaging

Introduction. It is thought that socioeconomic status and cultural upbringing influence the patient based outcomes of total joint arthroplasty. Previous studies have shown that patients in a lower socioeconomic class had surgery at an earlier age, increased comorbidities, increased severity of symptoms at presentation, and less satisfaction with the outcome. The purpose of this study was to compare the 1) reasons for undergoing total joint replacement and 2) satisfaction with the outcome among patients in different cultures and socioeconomic categories. We hypothesized that the overall reasons for undergoing surgery would be similar among all groups. Method. Patients undergoing total hip or knee arthroplasty were divided into groups based on their country of residence and socioeconomic status. The patients were asked to rank their reasons for undergoing surgery preoperatively from 1 to 4 according to importance. They were also asked to state how much relief of pain or improvement in function they expected to obtain. They were then asked to complete a questionnaire assessing their satisfaction with surgery 6 months post-operatively. These results were then compared across the three groups. Results. Thirty Nepalese patients and 10 American patients who received total hip or knee arthroplasty as part of a charitable outreach program were compared with 20 age and sex matched American patients who electively underwent total hip or knee arthroplasty. In both the Nepalese and outreach American patients, pain relief followed by improvement in performing everyday actions were listed as the most important reasons for undergoing surgery. The control group of American patients who sought surgery electively listed pain relief followed by improvement in performing individual activities as the main reasons for undergoing surgery. As compared to the other groups, the elective patients ranked athletic improvement higher as a reason for undergoing surgery. A review of the post-operative questionnaires completed by the Nepalese and American outreach patients showed that all were satisfied with the outcome of surgery and reported improvement in pain and the ability to perform individual as well as everyday activities. The postoperative questionnaires completed by the elective American patients showed satisfaction with the surgery, however, they reported less improvement in all functional categories. Conclusion. We found that, despite socioeconomic status, the reasons for undergoing total joint arthroplasty were similar among all groups. Pain relief was the most important reason for having surgery. There was a tendency for elective patients to rank participation in athletic activities higher than those in the lower socioeconomic groups. All patients were satisfied with their outcomes. However, the degree of subjective improvement among elective patients was less than that in lower socioeconomic groups. This may be due to the fact that, due to their lack of access to care, patients in lower socioeconomic groups had more severe disease prior to surgery

Distal radius fractures are common, yet the long-term functional outcome of these patients is unknown. This study investigated the long-term functional outcomes after distal radius fracture (DRF) in adult patients 16–23 years following injury. Secondary aims were to establish morbidity, mortality and function related to pattern of injury and patient demographics. Methods. 622 consented adult patients with a DRF were enrolled in the study. Prospective data was recorded; patient age, mechanism of injury and fracture pattern. Patients were assessed 16–23 years post-injury. 275 patients were deceased. 194 patients were able to complete a Quick Dash (QD) validated upper limb pain and function Patient-Reported Outcome Measure (PROM). Five patients declined follow-up. Socioeconomic status was assessed using the Scottish Index of Multiple Deprivation (SIMD) 2009. Results. The mean age at injury was 41 years for men and 64 for women in the initial cohort. 146 women and 48 men completed final follow-up. The mean age at QD assessment was 57 years for men and 76 for women; mean and median SIMD deciles were 6.7 and 7, respectively, for both genders. The mean QD score was 10.35 for all patients, with no significant gender difference (p=0.63). 85.6% (n=166) reported no or at most, mild limitation. High socioeconomic status, absence of other injuries at DRF and age under 85 years old at follow-up was associated with better long-term function. Early function and pain predicted long-term function; comminution pattern, treatment modality as chosen by surgeon, and early complications did not. Mortality data was analysed for the deceased (n=275). The mean patient survival from DRF to death was 11 years 5 months, with no significant gender difference (p=0.43); survival was predicted by age at injury, post-treatment dorsal angulation and early function. Respiratory, cardiovascular causes and malignancy were the three most common primary causes of death

Introduction. Social determinants of health (SDOH) may contribute markedly to the total cost of care (COC) for patients undergoing elective total knee arthroplasty (TKA). This study investigated the association between demographics, health status, and SDOH on lengths of stay (LOS) and 30-day COC. Methods. Patients who underwent TKA between January 2018 and December 2019 were identified. Those who had complete SDOH data were utilized, leaving 234 patients. Data elements were drawn from the Chesapeake Regional Information System, the Center for Disease Control social vulnerability index (SVI), the Food Access Research Atlas (FARA). The SVI identifies areas vulnerable to catastrophic events, with 4 themed scores including: (1) socioeconomic status; (2) household composition and disability; (3) minority status and language; and (4) housing and transportation. Food deserts were defined as neighborhoods located 1 or 10 miles from a grocery store in urban and rural areas, respectively. Multiple regression analyses were performed to determine an association with LOS and cost, after controlling for demographics. Results. Increased 30-day COC associated with SVI theme 3, (3.074 days; p=0.001) and patients who lived in a food desert ($53,205; p=0.001), as well as those who had anemia ($16,112; P = 0.038), chronic obstructive pulmonary disease ($32,570, P = 0.001), congestive heart failure ($30,927, P = 0.003), and dementia ($33,456, P = 0.008). Longer hospital lengths of stay were associated with SVI theme 3. In addition, patients who had anemia and congestive heart failure were at risk for longer hospital lengths of stay (P < 0.001, P = 0.001, respectively). Conclusion. Higher SVI theme 3 scores and living in food deserts were risk factors for increased LOS and costs, respectively. Identifying social factors including a patient's transportation options, living situation and access to healthy foods may prove to be both prognostic of outcomes and an opportunity for intervention

Rotator cuff repair (RCR) can be performed open or arthroscopically, with a recent dramatic increase in the latter. Despite controversy about the preferred technique, there has been an increase in the number of repairs performed arthroscopically. The purpose of this study was, therefore, to compare revision rates following open and arthroscopic RCR repair. Adult patients undergoing first-time, primary rotator cuff repair in Ontario, Canada (April 2003-March 2014) were identified using physician billing and hospital databases. Patients were followed for a minimum of two and up to 13 years for the primary outcome, revision rotator cuff repair, and secondary outcome, surgical site infection. The intervention considered was open versus arthroscopic technique. Patient factors (age, gender, residence, socioeconomic status, medical comorbidities) and provider factors (surgical volume, hospital setting, worked night before, year of surgery) were recorded. Standardized mean differences were used for covariate comparison. A Cox Proportional Hazards model was used to compare RCR survivorship between the two groups after adjustment for patient and provider factors, generating hazard ratios with 95% confidence intervals (HR, 95% CIs). Censoring occurred on the first of the primary outcome, death, shoulder arthroplasty or arthrodesis, or the end of the follow-up period (March 2016). A total of 37,255 patients were included. The overall revision RCR rate was 2.9% (1,096 patients) with a median time to revision of 23 months (IQR 12–52). Revision repair was more common in the arthroscopic group in comparison to the open group (3.2% vs 2.6%, NNT 166.7, p=0.004), with an adjusted HR of 0.72 (0.63–0.83 95% CI, p < 0 .0001). The surgical site infection rate was significantly higher in the open group compared with the arthroscopic group (0.5% vs 0.2%, NNT 333.3, p < 0 .001). Patient and provider covariates had no statistically significant effect on revision rates, aside from increasing age (per 10 year increase, HR 0.85, 0.81–0.90 95% CI, p < 0 .0001). Revision rotator cuff repair is approximately 30% more common in patients undergoing arthroscopic repair, in comparison to open repair, after adjustment. Surgical site infection is uncommon regardless of surgical technique, however, it is slightly more common following open repair. In the setting of an economic healthcare crisis, trends of increasing arthroscopic RCR may demand scrutiny, as the technique is associated with higher revision rates and higher costs

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

Introduction. Cephalomedullary nails (CMN) are commonly used for the treatment of intertrochanteric (IT) hip fractures. Total hip arthroplasty (THA) is commonly used as a salvage procedure for failed IT hip fractures that progress to post-traumatic arthritis. This study analyzed the complications of THA following treatment of failed IT hip fractures with cephalomedullary nails. Methods. Patients who had a primary THA were identified from the 5% subset of Medicare Parts A/B from 2002–2015. A subgroup with previous CMN for IT hip fracture within the previous 5 years was identified and compared to the remaining THA patients without prior CMN. Length of stay (LOS) was compared using both univariate and multivariate analysis. Infection, dislocation, revision, and readmission were compared between those with and without prior CMN, using multivariate analysis (adjusted for demographic, hospital, and clinical factors). Results. 5% subset of the Medicare data yielded 56,522 primary THA, with 369 treated with prior CMN. The percentage of primary THA from 2002–2005 with prior cephalomedullary nails (0.346%) more than doubled in 2012–2015 (0.781%). The prior CMN group tended to be older, female, higher CCI, and lower socioeconomic status. Mean LOS was 1.5 days longer (5.3 vs 3.8) in the prior CMN group (p<0.0001). The percentage of postoperative complications was significantly higher in the prior CMN group compared to non-CMN cohort: infection (6.2% vs 2.6%), dislocation (8.1% vs 4.5%), revision (8.4% vs 4.3%), revision for infection (1.1% vs 0.37%), and revision for dislocation (2.2% vs 0.6%). Discussion. Conversion from failed IT hip fractures with cephalomedullary nails to total hip arthroplasty continues to increase. These cases occur in elderly patients with increased comorbidities. There is a significantly increased risk of infection, dislocation and LOS in the CMN group. Patients with failed IT hip fractures undergoing THA should be made aware of the increased complication risk and further steps need to be undertaken to diminish the elevated risk