In 2007, the National Hip Fracture Database (NHFD) was conceived in the United Kingdom (UK) as a national audit aiming to improve hip fracture care across the country. It now represents the world's largest hip fracture registry. The purpose of the NHFD is to evaluate aspects of best practice for hip fracture care, at an institutional level, that reflect the evidence-based clinical guidelines and quality standards developed by the National Institute for Health and Care Excellence. No national program currently exists, equivalent to the NHFD, in Canada despite evidence suggesting that national audit programs can significantly improve patient outcomes. The purpose of this study was to evaluate aspects of best practice for hip fractures at our Canadian academic tertiary referral center using the Key Performance Indicators (KPI) and benchmarks used by the NHFD. In doing so, we aimed to compare our performance to other hospitals contributing to the NHFD database.

A retrospective cohort study was conducted on consecutive patients who presented to our Canadian center for surgical management of a hip fracture between August 2019 to September 2020. Fracture types included intertrochanteric, subtrochanteric, and femoral neck fractures treated with either surgical fixation or arthroplasty. Cases were identified from the affiliate institute's Operatively Repaired Fractures Database (ORFD). The ORFD prospectively collects patient-level data extracted from electronic medical records, operating room information systems, and from patients’ discharge summaries. All applicable data from our database were compared to the established KPI and benchmarks published by the NHFD that apply to the Canadian healthcare system.

Six hundred and seven patients’ data (64.5% female) were extracted from the ORFD, mean age 80.4 ± 13.3 years. The NHFD contains data from 63,284 patients across the entire UK. The affiliate institute performed inferiorly compared to the NHFD for two KPIs: prompt surgery (surgery by the day following presentation with hip fracture, 52.8% vs. 69%) and prompt mobilization after surgery (mobilized out of bed by the day after operation, 43.0% vs. 81.0%). However, more patients at the affiliate institute were not delirious when tested postoperatively (89.6% vs. 68.4%). There was no significant difference in the average length of stay (12.23 days versus 13.5 days) or in 30-day mortality rate (8.4% versus 8.3%).

More than half of all KPI's and benchmarks for patients receiving a hip fracture surgery at our tertiary referral center in Canada ranked significantly lower than patients receiving a hip fracture surgery in the UK. These findings indicate that perhaps a national audit program should be implemented in Canada to improve aspects of hip fracture care, at an institutional level. Following evidence-based clinical guidelines and using standardized benchmarks would encourage change and foster improvement across Canadian centres when necessary.

In patients admitted to hospital with a hip fracture, urinary issues are common. Despite guidelines that recommend avoiding foley catheter usage when possible, it remains a common part of perioperative care. To date, there is no prospective data on the safety and satisfaction associated with catheter use in such cohort. The aim of this study was to evaluate the satisfaction of patients when using a foley catheter while they await surgery for their fractured hip and the safety associated with catheter use.

In our prospectively collected database, 587 patients were admitted to our tertiary care center over a 1 year period. Most patients (328) were catheterized within the first 24h of admission, primarily inserted in ED. Of these patients, 119 patients (61 catheterized and 58 noncatheterized) completed a questionnaire about their perioperative management with foley catheter usage administered on day 1 of admission. This was used to determine satisfaction of catheter use (if catheterized) and pain levels (associated with catheterized or associated with transferring/voiding if not catheterized). Adverse effects related with catheter use included urinary tract infection (UTI) and post-operative urinary retention (POUR).

Ninety-five percent of patients found the catheter to be convenient. Only 5% of patients reported any pain with catheter use. On the contrary, 47.5% of non-catheterized patients found it difficult to move to the bathroom and 30.4% found it difficult to urinate. Catheterized patients had significative less pain than uncatheterized patients (0.62/10 vs 2.45/10 respectively, p < 0 .001). The use of nerve block reduced pain levels amongst catheterized patients but was not associated with reduced pain levels or satisfaction amongst non-catheterized patients. The use of catheter was not associated with increased risk of UTI(17.5% in the catheterized vs 13.3% in the non-catheterized, p = 0.541) or POUR (6.8% in the catheterized vs 11.1% in the non-catheterized, p = 0.406).

This study illustrates the benefits and safety associated with the use of urinary catheters in the pre-operative period amongst hip fractures. The use of catheters was associated with reduced pain and satisfaction without increasing post-operative UTI or POUR. These findings suggest that pre-operative catheter use is associated with less pain and more satisfaction for patients awaiting hip surgery and whom other measures, such as nerve blocks, are unlikely to reduce the discomfort associated with the mobility required to void. A prospective randomized control study could lead to a more evidence based approach for perioperative foley catheter usage in hip fracture patients.

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome.

This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF.

Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome.

The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF.

The clinical guidelines for hip fracture management indicate that indwelling foley catheterization should be avoided when possible. Alternatives to indwelling catheters such as intermittent or condom catheters are recommended. Appropriate catheterization usage is important in hip fracture patients to avoid complications such as urinary tract infections (UTIs) (7–24% of patients) or post-operative urinary retention (POUR) (20–56% of patients). In this study, we aim to, (1) evaluate catheter usage in hip fracture patients at a large tertiary care centre, (2) compare current practices in catheter usage to clinical guidelines, (3) determine the incidence of POUR in hip fracture patients (4) determine the factors that increase one's risk of developing POUR.

We analyzed 584 hip fracture patients between the ages of 18 and 102 admitted between November 2015 and October 2017 at a tertiary Care Hospital. Data collected included patient demographics, fracture pattern, surgical procedure, length of stay, co-morbidities and catheter use. We compared actual catheter usage to suggested guidelines to determine whether recommendations were being followed. We also investigated the incidence of POUR and risk factors associated with developing POUR. Independent samples t-test were used to compare continuous dependent variables in bivariate analyses and a logistic regression was used to determine predictors of developing POUR, catheter usage, and length of stay in multivariate analyses. T

Over three quarters (76.9%) of patients with hip fractures were treated with a catheter during their admission, 63.5% of which were inserted pre-operatively and 36.5% of which were inserted post-operatively. Indwelling catheters accounted for 92.2% of catheters used, while intermittent and catheter condoms accounted for 7.8%. POUR occurred in 98 of 584 cases (16.7%). Age (p = 0.004), gender (p=0.001), and presence of kidney disease (p=0.033) were statistically significant predictors of POUR. Fracture pattern (p=0.825), surgical procedure (p=0.298), diabetes mellitus (p=0.309) and UTI in the past 60 days (p=0.848) or on admission (p=0.999) were not statistically significant predictors of developing POUR. The development of POUR did not significantly increase length of stay (p=0.558). There was no statistically significant correlation between developing POUR and extended post-operative catheter use over 24 hours (p=0.844) or 48 hours (p=0.862). Patients who received a catheter pre-operatively or post-operatively for longer than 24 hours were not significantly more likely to develop POUR (p=0.057).

Catheter use was common for all hip fracture patients and indwelling catheters were used in the overwhelming majority of cases. The high frequency of catheter usage, and specifically indwelling catheter usage, suggests that there is low compliance with the clinical guidelines for hip fracture patients. The incidence of POUR was 17%. Older, male patients were more likely to develop POUR. Although not statistically significant, more appropriate catheter use may decrease urinary complications such as POUR.

The benefit of using a long intramedullary device for the treatment of geriatric intertrochanteric hip fractures is unknown. The InterTAN device (Smith and Nephew, Memphis TN) is offered in either Short (180–200 mm) or Long (260–460 mm) constructs and was designed to provide stable compression across primary intertrochanteric fracture fragments. The objective of our study was to determine whether Short InterTANs are equivalent to Long InterTANs in terms of functional and adverse outcomes for the treatment of geriatric intertrochanteric hip fractures.

108 patients with OTA classification 31A–1 and 31A–2 intertrochanteric hip fractures were included in our study and prospectively followed at one of four Canadian Level-1 Trauma Centres. Our primary outcomes included two validated primary outcome measures: the Functional Independence Measure (FIM), to measure function, and the Timed Up and Go (TUG), to measure motor performance. Secondary outcome measures included blood loss, length of procedure, length of stay and adverse events. A pre-injury FIM was measured by retrospective recall and all postoperative outcomes were assessed on postoperative day 3, at discharge, at 6 weeks, 3 months, 6 months and 12 months postoperatively. Unpaired t-tests and Chi-square tests were used for the comparison of continuous and categorical variables respectively between the Short and Long InterTAN groups. A statistically significant difference was defined as p<0.05.

Our study included 71 Short InterTAN and 37 Long InterTAN patients with 31A–1 and 31A–2 intertrochanteric hip fractures. Age, sex, BMI, side, living status and comorbidities were similar between the two groups. The mean operative time was significantly lower in the Short InterTAN group (61 mins) as compared to the Long InterTAN group (71 mins)(p0.05). There were 5 periprosthetic femur fractures in the short InterTAN group versus 1 in the long InterTAN group. Non-mechanical adverse outcomes such as myocardial infarction, pulmonary embolism, urinary tract infections, pneumonia and death all had similar incidence rates between the two InterTAN groups.

Both the Short and Long InterTAN patient cohorts displayed similar improvements in performance and overall function over the course of a year following intertrochanteric hip fracture fixation. The recorded operative times for Short InterTAN fixation were significantly shorter than those recorded for the Long InterTAN patients. Alternatively, a significantly higher proportion of Short InterTAN patients sustained periprosthetic femur fractures within a year of implantation as compared to the Long InterTAN group.

Fractures of the anteromedial facet (AO/OTA 21-B1.1, O'Driscoll Type 2, subtype 3) are associated with varus posteromedial rotational instability of the ulnohumeral joint and early post-traumatic arthritis. The purpose of this study was to examine the stability of plate (locking and non-locking) vs screw constructs in the fixation of anteromedial coronoid facet fractures in a sawbone model.

An anteromedial coronoid facet fracture (AO/OTA 21-B1.1) was simulated in 24 synthetic ulna bones. They were then assigned into 3 fracture fixation groups: non-locking plate fixation, locking plate fixation, and dual cortical screw fixation. An AO 2.0 mm screw and plate system was used for the plate fixation groups and 2.0 mm cortical screws were used for the screw-only group. Following fixation, each construct was potted in bismuth alloy and secured to a servohydraulic load frame. Each construct was cycled in tension and then in compression at 0.5Hz. For both cycling modalities, an incremental loading pattern was used starting at 40 N and increased by 20 N every 200 cycles up to 200N. Fracture fragment displacement was recorded with an optical tracking system. Following cyclic loading each construct was loaded to failure (displacement >2 mm) at 10mm/min.

Tension cycling – All constructs in the plated groups (locking and non-locking constructs) survived the cyclic tension loading protocol (to 200N) with maximum fragment displacement of 12.60um and 14.50um respectively. There was no statistical difference between the plated constructs at any load level. No screw-only fixed construct survived the tension protocol with mean force at failure of 110N (range 60–180N).

Compression Testing – All constructs in the plated groups (locking and non-locking constructs) survived the cyclic compression loading protocol (to 200N), while all but one of the screw-only fixation constructs survived. Fracture fragment displacement was significantly greater in the screw-only repair group across all loading levels when compared to the plated constructs. There was no statistically significant difference in fragment motion between the locking and non-locking groups.

Failure Testing – The maximum load at failure in the screw-only group (281.9 N) was significantly lower than locking and non-locking constructs (587.0 N and 515.5N respectively, p <0.05). There was no difference between the locking and non-locking group in mean load to failure or mean stiffness. Screw construct stiffness (337.2 N/mm) was lower than the locking and non-locking constructs (682.9 N/mm and 479.1 N/mm respectively) however this did not reach statistical significance (p=0.051).

Fixation of anteromedial coronoid fractures is best achieved with a plating technique. Locking plates did not offer any advantage over conventional plates. Isolated screw fixation might not provide adequate stability for these fractures which could result in loss of reduction leading to post-traumatic arthrosis or instabilility.

Traditional screw fixation of the syndesmosis can be prone to malreduction. Suture button fixation however, has recently shown potential in securing the fibula back into the incisura even with intentional malreduction. Yet, if there is sufficient motion to aid reduction, the question arises of whether or not this construct is stable enough to maintain reduction under loaded conditions. To date, there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress CT model.

Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator frame that allows for the application of sustained torsional (5 Nm), axial (500 N) and combined torsional/axial (5Nm/500N) loads. Baseline CT scans of the intact ankle under unloaded and loaded conditions were obtaining. The syndesmosis and the deltoid ligament complex were then sectioned. The limbs were then randomised to receive a suture button construct tightened at 4 kg force (loose), 8 kg (standard), or 12 kg (maximal) of tension and CT scans under loaded and unloaded conditions were again obtained. Eight previously described measurements were taken from axial slices 10 mm above the tibiotalar joint to assess the joint morphology under the intact and repair states, and the three loading conditions: a measure of posterolateral translation (a, b), medial/lateral translation (c, g), a measure of anterior-posterior translation (f), a ratio of anterior-posterior translation (d/e), an angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula, and an angle (Angle 2) created between the medial surfaces of two malleoli. These measurements have all been previously described. Each measurement was taken at baseline and compared with the three loading scenarios. A repeated measures ANOVA with a Bonferroni correction for multiple comparisons was used to test for significance.

Significant lateral (g, maximum 5.26 mm), posterior (f, maximum 6.42 mm), and external rotation (angle 2, maximum 11.71°) was noted with the 4 kg repair when compared to the intact, loaded state. Significant posterior translation was also seen with the both the 8 kg and 12 kg repairs, however the incidence and magnitude was less than with the 4 kg repair. Significant overcompression (g, 1.69 mm) was noted with the 12 kg repair.

Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. If inserted too loosely, these constructs allow for supraphysiologic motion which may have negative implications on ligament healing. These constructs also demonstrate overcompression of the syndesmosis when inserted at maximal tension however the clinical effect of this remains to be determined.

Purpose

Based on anatomic studies, it appears that the short head (SH) and long head (LH) of the distal biceps tendons have discreet distal attachments on the radial tuberosity. The SH attaches distally and therefore may function as a stronger flexor, whereas the LH attaches more proximal and ulnar which would make it a greater supinator. The contribution of each of the two heads to flexion and supination has not yet been defined. The rationale of this study was to directly measure the contribution of the SH and LH of the biceps to elbow flexion and forearm supination and provide biomechanical evidence for what is inferred in the anatomical studies.