We compared the mortality of hip fracture patients treated in teaching versus community hospitals in Ontario. Hip fracture patients ≥ 50 yrs were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database and linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

The purpose of this study was to compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario.

Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

This finding will have far-reaching implications for health policy in this province. Hip fracture (ICD-9 code 820) patients ≥ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and twelve months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

We compared the mortality of hip fracture patients treated in teaching versus community hospitals in Ontario. Hip fracture patients ≥ 50 yrs were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database and linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

To compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals. This finding will have far-reaching implications for health policy in this province. Hip fracture (ICD-9 code 820) patients ≥ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and twelve months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

Introduction and Aims: There is significant mortality during the first year after hip fracture. US studies indicate that mortality is lower in teaching than non-teaching hospitals for hip fracture patients. Our aim was to compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario.

Method: Hip fracture (ICD-9 code 820) patients ³ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Results: Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and 12 months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

Conclusion: Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals. These findings have enormous implications for healthcare providers and health policy-makers.

Introduction and Aims: There is very little scientific evidence of which activities to avoid or which are safe following total hip arthroplasty (THA). Our aims were to conduct a survey of Canadian orthopaedic surgeons’ exercise recommendations after THA and to examine the relation between physical activities and hip pain in THA patients.

Method: Patients who had a primary THA five to seven years previously because of osteoarthritis were administered the well-validated Minnesota Leisure-Time Physical Activity Questionnaire, which assesses the frequency, intensity and duration of physical activities. Patients reported on current physical activities and sports and recalled activity two years after their surgery. They also reported whether they had pain in the affected hip during specific activities and if they reduced their activity because of pain. A survey was mailed to 466 Ontario orthopaedic surgeons to determine the types of physical activities recommended to patients following THA.

Results: Results of the surgeon survey indicate that all surgeons allowed walking, stair climbing and swimming. Nearly all did not allow jogging, squash or racquetball. There was considerable disagreement among the surgeons regarding other activities, e.g., downhill skiing and heavy household activities. Seventy-one male (mean age ± SD; 61 ± 8) and 97 female (61 ± 7) THA patients were interviewed. Over 80% of respondents reported bending and lifting activities. About half the respondents reported non-weightbearing activities such as swimming. A higher proportion of men than women reported golf, racquet sports and shovelling snow, whereas a higher proportion of women than men reported doing housework. Hip pain was most frequently reported during lifting and bending activities. Patients were least likely to report pain during non-weightbearing activities. Nearly all patients who reported pain, reduced their activity level. Thus our preliminary data suggest that bending and lifting impact activities appear to cause the most pain and result in reduced activity levels. Our results also show that some patients participate and experience pain in non-recommended activities. Some allowed activities, such as stair climbing, cause pain.

Conclusion: Bending and lifting activities cause the most pain and result in reduced activity. Patients participate and experience pain in activities that surgeons do not recommend. Some recommended activities cause pain. This is one of the first studies to quantify activity and show a relation between activities and pain in THA patients.

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented.

Methods The material presented consists of a review of published literature and personal experience.

Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment.

Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery.

Introduction The unique aspects of the Comprehensive AO classification is discussed.

Methods The unique feature of this system of classification is that it’s principles and the classification itself are not based on the regional features of a bone or its fracture patterns. It is not bound by convention of usage or the popularity of an eponym. It is generic and applies to the whole skeleton. It’s guiding philosophy is that a classification is worthwhile only if it helps in evolving the rationale of treatment and in the evaluation of the outcome of that treatment. The classification must therefore indicate the severity of the fracture, which in this case indicates the morphological complexity of the fracture, the difficulties to be anticipated in treatment, and it’s prognosis. This has been accomplished by formulating the classification on the basis of repeating triads of fracture types, their goups and subgroups and by arranging the triads and the fractures in each triad in an ascending order of severity. Thus there are three fracture types A, B, and C in an ascending order of severity. Each fracture type has three groups and each group three subgroups. The identification of the Type indicates immediately the severity. The classification considers a long bone to have a diaphyseal segment and two end segments. It makes use of the rule of squares to define the end segments with great precision. The location of the fracture has also been simplified by noting the relationship which the center of the fracture bears to the segment. A new terminology has been developed. In order to provide a check list of essential data which must be available before a fracture can be classified, the Comprehensive Classification System has a system of binary questions which allow the classifier to determine precisely whether all the essential data necessary is available. If not, further imaging may be necessary. To facilitate computer entry and retrieval of the cases, an alphanumeric code has been created. The diagnosis of a fracture is given by coupling the location of the fracture with its morphologic complexity.

Results The developed terminology is so precise that it is now possible to describe a fracture verbally with such accuracy that it’s pictorial representation is superfluous.

Conclusions Once the surgeon has accurately classified the fracture, he can, basing himself on information available from the literature and on his own experience make proper decision regarding it’s treatment.

Introduction A review of the treatment of distal femoral non-union and mal-union by intra-articular osteotomy is presented.

Methods It is based on a review of the literature and personal experience.

Results Articular fractures are of three basic types: split wedge fractures, split wedge depression and pure depression. Intra-articular osteotomies are easiest for pure split wedge fractures which have gone on to a mal-union because one can quite easily identify the original fracture line and then recreate it surgically at operation. Any callus which has formed during healing can also be resected to make the fragments fit. Corrective osteotomies are still possible, although more difficult, for split wedge fractures combined with joint depression, the so called split wedge depression type of fractures, which have mal-united. However, pure depression intra-articular fractures which have gone on to union cannot be reconstructed by means of an intra-articular osteotomy because it is impossible to recreate the original fracture lines. This fact emphasizes the importance of reducing and stabilizing intra-articular fractures as early as possible because of their rapid union and subsequent difficulties if one tries to correct the mal-unions. Post-traumatic arthritis develops as result of damage to the articular cartilage at the time of the trauma, as result of joint incongruity, axial deformity and resultant joint overload, and joint instability. Joint incongruity and axial deformity result in post-traumatic arthritis because of increase in stress beyond the tolerance of articular cartilage. Stress is the result of force distributed over available surface area S= F/A. Joint incongruity decreases available surface area and increases stress. Axial deformity because of overload increases force which increases stress. Instability on the other hand results in shearing forces which lead to rapid articular cartilage destruction. Instability is more malignant for a joint then excessive stress and leads more rapidly to joint destruction.

Conclusions From the above it is evident that the objectives in treatment of an intra-articular ma-lunion and non-union is to: Restore joint congruency and normal anatomy, correct axial malalignment, restore joint stability and restore joint mobility.

Introduction A review of the the treatment of supracondylar fractures of the distal femur is presented.

Methods The material presented consists of a review of published literature and personal experience.

Results The introduction of the Condylar Blade Plate by the AO in the 1960s revolutionized the treatment of this injury. Numerous publications over the last 30 years attest to the superiority of the modern AO methods. The Comprehensive Classification of the supracondylar fractures greatly helps surgeons in decision making. The mid-line medial parapatelar surgical approach is preferred to the classical lateral incision. A lateral parapatellar incision has been in use recently in conjunction with the LISS and CLCP. A detailed understanding of the surgical anatomy of the distal femur prevents technical misadventures in securing stable fixation. Atraumatic reduction techniques have been developed to prevent devitalization of intermediate fragments which permits bridge plating and obviates the need of bone grafting multifragmentary fractures. Previously, failure to bone graft multifragmentary fractures was the commonest cause of failure of fixation. Current fixation devices are the classic condylar plate, the dynamic condylar screw, the condylar buttress plate, and the retrograde supracondylar femoral nail and the most recently developed LISS and the condylar locked compression plate. The choice of implant depends on the specific fracture pattern and associated soft tissue injury, concomitant apendicular and system injuries, the patient’s age and the presence of osteoporosis. The open supracondylar fracture presents unique problems which require careful judgement and staging in reconstruction. Even if they become infected, with proper stabilization 80% will still achieve satisfactory results. The supracondylar fracture in the presence of a total knee replacement is an absolute indication to surgical stabilization. It and osteoporosis present specific challenges which require specialized techniques of fixation for successful resolution. Polytrauma with multisystem injuries and certain specific concomitant articular injuries such as patellar fractures or fractures of the tibial plateau prejudice the outcome of treatment.

Conclusions With modern surgical treatment, young patients with isolated Type A, Type B and C1 or C2 fractures can expect a normal knee as the outcome of treatment. Type C3 fractures and open fractures continue to be a challenge and their outcome depends on the degree of initial articular cartilage destruction, the degree of bone fragmentation and displacement, and on the degree of soft tissue damage. Articular cartilage injury and severe osteoporosis continue to be the two most important unsolved problems in fracture surgery.

We reviewed 64 patients in whom 66 acetabula had been reconstructed with either the Muller ring (46) or the Burch-Schneider anti-protrusio cage (20) at a mean follow-up of five years. Five hips had been revised a second time for loosening, all after a Muller ring had been used for a medial segmental defect (2), ungrafted cavitary defects (2) or after resorption of a block graft (1). The use of bone grafts with the implants reduced the incidence of failure from 13% to 6% and of circumferential radiolucent lines at the bone-implant interface from 39% to 2%. The Muller ring is indicated for acetabula with isolated peripheral segmental defects or cavitary defects confined to one or two sectors. The Burch-Schneider cage should be used for medial segmental defects, extensive cavitary defects and combined deficiencies. Defects should be reconstituted with bone graft rather than cement.

1. Thirty-seven cases of fracture of the dens have been studied.

2. The incidence of non-union was high: 64 per cent after apparently adequate closed treatment.

3. Possible causes of the high incidence of non-union have been studied : attention is drawn to the effect of displacement and to that of posterior displacement in particular.

4. Non-union of the dens with potential instability at the atlanto-axial joint is not acceptable in a patient who expects to lead a normal active life.

5. Atlanto-axial fusion is the method of choice in the treatment of instability ; once that has been secured, pseudarthrosis of the dens is no longer significant.

1. The syndrome of spinal stenosis is due to compression of the cauda equina from structural narrowing of the lumbar spinal canal.

2. Patients with this syndrome present symptoms of cauda equina claudication or of unremitting bizarre back pain and sciatica.

3. The compression of the cauda equina is always posterior and postero-lateral and is caused by narrowing of the lateral recesses and of the dorso-ventral diameter of the spinal canal.

4. The diagnosis can be made only by myelography. The only form of successful relief of the nerve root compression in spinal stenosis is adequate lateral and longitudinal decompression.