Aims

This study reviews the past 30 years of research from the Canadian Orthopedic Trauma Society (COTS), to identify predictive factors that delay or accelerate the course of randomized controlled trials in orthopaedic trauma.

Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed.

Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma.

A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice.

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit (p<0.0001). All AMTS were completed in accordance with instructions, whereas almost half of CDTs were incompletely or incorrectly filled out (45%).

The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed.

Purpose: surgical fixation distal femoral fractures has been associated withnonunion and varus collapse. the soft tissue stripping esulted from this fracture and caused by the surgical approach have been factorassociated with delayed union and infection. the limited soft tissue exposure has been lauded as a solution to this fracture. however, it has occurred with new fixation as well (locked plate) this study is an attempt to look at the fixation from the surgical approach prospective. does the liss system improve the results of this difficult fracture? is there truly a difference in the outcome of this fracture utilizing the locked plate system or the percieved difference due to surgical mini invasive approach.

Method: one hundred and forty patientswere screened, and only 53 were randomized and treated in six academic centers over five years. all c3 fractures were excluded from the study as they were felt not to be treatable by the dcs device, but they were treated and fixed appropiately. thirty five females and 18 males were included and appropiately randomized.

Results: fifty three patients were randomized, 28 had the liss implant while 25 had the dcs utilized. there were three nonunions in the liss group, plus two patients required an early reoperation in the early post operative periods ( second – fifth post op. day) due to an early loss of reduction. further more, one patient developed a knee arthrofibrosis that required arthroscopic joint release with subsequent implant failure. that necessiated a reoperation. in the dcs group there was only one nonunion, that required reoperation. this translated into reoperation rate of 21%in the liss group compared to 4% with dcs.

Conclusion: this prospective multicenter randomized trial showeda significant difference when comparing the liss device to the dcs system in minimal invasive approach of distal femoral fractures fixation

Purpose: Proximal humeral fractures are a commonplace injury, especially in the elderly population. Management is not always straightforward, and is particularly challenging when bone quality is poor. In recent years, locking plates have become available for the internal fixation of many types of fractures, including those of the proximal humerus, and a growing trend in their use has been noted. This is a randomized biomechanical study to evaluate the mechanical stability in simulated osteoporotic bone of three fixation plates, two locking and one conventional, for unstable two-part proximal humeral fractures.

Method: Eighteen synthetic left humeri were plated with six bones in each of three groups: Synthes Cloverleaf Plate, Synthes Locked Compression Plate Proximal Humerus, and Smith and Nephew Periarticular Locking Plate for Proximal Humerus. Screw holes were overdrilled to simulate osteoporotic purchase. The distal humeral condyles were potted in autobody cement in polyvinylchloride tubes. An eight millimeter osteotomy gap was made at the base of the greater tuberosity to simulate an unstable two-part fracture. Cyclic axial compression testing was done in the vertical plane in 20 degrees of abduction to simulate physiologic loading. Measurements of plastic deformation of the construct were quantified by comparing RSA images taken before and after loading. Following cyclic axial compression testing, quasi-static torsion testing was done in the horizontal plane until construct failure. Failure was defined as the point where the linearity of a load-displacement curve is lost or where visible failure of the fixation occurs.

Results: No plates were loaded to failure. The locked plates were significantly stiffer in axial compression and torsion than the Cloverleaf plate. There was no difference between locked plates. The maximum total point motion seen on the RSA analysis was more than 4 times greater in the Cloverleaf group relative to either locked construct and no difference between the Synthes and Smith and Nephew locked plates was again seen. The majority of the motion in the Cloverleaf construct appeared to be in rotation about the anteroposterior axis (lateral rotation).

Conclusion: This study supports that locked plates, regardless of manufacturer, are stiffer in axial compression and torsion than Cloverleaf plates and result in less displacement in an unstable fracture pattern in an osteoporotic bone model.

Purpose: The ideal bearing surface for total hip arthroplasty is still an area of debate. Increasing numbers of total hip replacements are being done in the younger patient population. Ceramic-on-ceramic bearings have gained popularity due to their low wear rate; however, ceramic fractures with subsequent catastrophic failures have been reported and squeaking of ceramic hips is an emerging problem. This study reports on early results of ceramic-on-ceramic total hip replacements.

Method: This is a study analyzing prospectively collected data for 120 alumina-on-alumina total hip replacements with minimum follow up of 24 months. Average age at time of surgery was 49 years. The main outcome of the study was to identify complications related to the pros-theses. Standard outcome measures (SF-12, Harris Hip Score, and WOMAC) were also collected at clinic visits.

Results: All patients received either a Stryker Trident acetabular cup with Secure-fit Plus stem or Depuy Pinnacle cup with an AML stem. Average follow-up was five years (range: two – nine years). No revisions were performed for loosening or catastrophic failures. No wear, loosening, or osteolysis was seen on radiographs. The SF-12, WOMAC, and Harris Hip scores were not significantly different from other reported hip series. The most common complication has been the “squeaking” hip. To date we have had six squeaky hips in our centre, three of which have been revised. All the squeaking hips received the Trident acetabular cup (Stryker) which has a circumferential metal lip to protect the ceramic bearing. This metal flange can affect range of motion and predispose patients to earlier impingement (particularly if a minus 3 head is utilized). One patient with a Depuy hip complains of intermittent pain and radiographs show some fragmentation, but the hip has not been revised.

Conclusion: Ceramic-on-ceramic bearing surfaces in total hip arthroplasty may provide a more durable prosthesis with outcomes similar to standard THA, especially in young and active patients; however, caution should be used if considering the Stryker Trident shell due to the large number of “squeaky hips”.

Purpose: Intra-articular (IA) injections of corticosteroids and hyaluronic acid (HA) products are used to treat patients with knee osteoarthritis pain that has not responded to more conservative treatment. Corticosteroids are a standard of care despite only suggestive clinical evidence of 12 or more weeks of pain relief.

Method: A double-blinded, randomized, active controlled, multicenter non-inferiority trial with 442 subjects provided a pragmatic comparison of HA to methylprednisolone. Both groups received one intrar-ticular injection, and underwent pain and function evaluations over 26 weeks. The primary endpoint for study success was WOMAC pain responder rate at 12 weeks. The outcome of two prior trials influenced the patient selection criteria and provided a saline cohort for propensity score analyses comparing HA and methylprednisolone to saline.

Results: The responder rate of HA was non-inferior to methylprednisolone at 12 weeks. Reductions in WOMAC pain, stiffness and physical function scores at all time points, and improvements in time to ‘get-up-and-go’ and walk 10 meters occurred in both treatment groups. The trends favored the HA responder rates at the later time points while the methylprednisolone rate decreased significantly by 26 weeks. Propensity score analyses confirmed that the responder rates of meth-ylprednisolone and HA were statistically significantly superior to a saline control at 12 weeks.

Conclusion: The responder rate from a single injection of HA was non-inferior to methylprednisolone at 12 weeks, and the trend favored HA at later time points. The responder rates of HA and methylprednisolone were statistically significantly greater than that of saline at 12 weeks.

The Canadian Orthopaedic Trauma Society was started in an endeavour to answer the difficult problem of obtaining enough patients to perform top-quality research into fractures. By maintaining a high standard, including randomised study design, inclusivity, open discussion among surgeons and excellent long-term follow-up, this group has become a leader in the orthopaedic research community. This annotation describes the short history, important components and spirit necessary to build a research community or team which will function well despite the difficult research environment facing individual surgeons.

The purpose of this study was to compare the clinical outcome of patients treated surgically for end stage ankle arthritis using a total ankle arthroplasty or ankle arthrodesis.

This is a multicentered prospective clinical outcome study of the surgical treatment of patients with EAA using an ankle arthrodesis (n= 117) or total ankle arthroplasty (n= 210). Clinical outcome was assessed using health related quality of life (SF36v2) and joint specific (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopedic Foot and Ankle Hindfoot Scale and the AAOS Foot and Ankle Baseline Questionnaire(version 2000)) outcome scores.

Preoperatively, all patients had significant physical and psychological morbidity. All symptom and functional SF36 subscales were approximately two standard deviations below normal population scores. Approximately 25% of patients were three standard deviations below population values, indicating increased risk of mortality. There was no evidence that age or gender influenced the level of disability. There was a significant improvement in the health related quality of life and the joint specific clinical outcome scores at six and twelve months follow up but no consistent difference was noted between the two cohorts.

This is the first multicentered prospective clinical outcome study that demonstrates equal efficacy for early follow up of patients treated for EAA with total ankle arthroplasty or ankle arthrodesis.

The ideal bearing surface for total hip arthroplasty is still an area of debate.Increasing numbers of total hip replacements are being done in the younger patient population.Ceramic-on-ceramic bearings have gained popularity due to their low wear rate.However, ceramic fractures with subsequent catastrophic failures have been reported. This study reports on early results of ceramic-on-ceramic total hip replacements.

This is a study analyzing a prospectively collected data for seventy-five ceramic-on-ceramic total hip replacements with minimum follow up of eighteen months. Average age at time of surgery was forty-seven years. This study focused on the complications of this ceramic population. Complications included: One posterior dislocation, two intra-operative calcar fractures that needed wiring, one intra-operative fracture of the acetabular liner, two cases of impingement (one which resulted in a revision), and one periprosthetic fracture. The two patients that required further surgery were the periprosthetic fracture after a fall and one for component impingement. No revisions were performed for loosening or catastrophic failures. No wear, loosening, or osteolysis was seen on radiographs. The SF-12, WOMAC, and Harris Hip scores were not significantly different from other reported hip series.

Ceramic-on-ceramic bearing surfaces in total hip arthroplasty are a safe option with outcome equivalent to standard THR in the short term. Ceramic Hips may provide a more durable prosthesis, especially in young and active patients. Intra-operative technical guidelines that may enhance the quality of the results will be presented and fully disclosed.

The purpose of this study is to assess the clinical outcome and gait analysis of a new technique for ankle arthrodesis using a Fibular Sparing Z Osteotomy (FSZO).

The FSZO technique for ankle arthrodesis utilises a lateral approach where the fibula is osteotomised and reflected posteriorly on a soft tissue hinge to allow easy access to the ankle joint for an anatomic arthrodesis. Outcome assessment at six months follow up included health related quality of life (SF36) and joint specific (American Orthopedic Foot and Ankle Society Ankle-Hindfoot, Ankle Osteoarthritis Scale, Foot Function Index) clinical outcome scores. Gait Analysis was completed using the Walkabout Portable Gait Monitor® which includes a wireless gait belt housing a triaxial arrangement of accelerometers, resting behind the lumbar vertebrae, approximately at position of centre of mass to quatintfy surgery, lurch and functional limb length difference (LLD).

There was a significant improvement in the health related quality of life and the joint specific clinical outcome scores at six months follow up. The six month gait study preliminary analysis showed improvement in some parameters of gait but worsening in others.

The FSZO ankle arthrodesis technique provides improvement in clinical outcome scores and certain gait parameters at early follow up.

Purpose: The Less Invasive Stabilization System (LISS), Dynamic Condylar Screw (DCS) and Condylar Buttress Plate (CBP) are three common fixation methods for supracondylar femur fractures. The DCS and CBP are compression plates while the LISS uses locking screws to transfer load from bone to plate without compression. We developed a study to determine if the theoretical biomechanical advantages of the LISS would be evident in laboratory testing.

Methods: Identical AO type C fractures were created in eighteen composite femurs and fixed with either LISS, CBP, or DCS (6 each). Roentgen Stereophotogrammetric Analysis (RSA) was used for analysis. Reference markers were implanted into each bone segment. Biplanar x-rays were taken to give a three-dimensional representation of the fracture. The femurs were loaded axially in an Instron 1350 and subjected to cyclic loading (50kg ± 25 for 50000 cycles). After loading, the bones were x-rayed to determine relative motion between fracture segments. To examine inducible displacement under static loading, the femurs were x-rayed in an unloaded and loaded (50 kg) condition. Again, RSA was used for analysis.

Results: RSA-CMS software was used to analyze relative motion between the bone segments. After cyclic loading, the condylar buttress plate showed significantly more permanent deformation between the medial condyle and shaft of the femur than the DCS or LISS. Under static load, the LISS showed greater displacement than the other devices between the medial condyle and shaft, and between the lateral condyle and shaft.

Conclusions: The LISS demonstrated less permanent deformation but greater inducible deformation between the medial femoral condyle and femoral shaft, compared to the DCS and CBP. The results were statistically significant. These results may have clinical implications regarding the choice of fixation devices for this difficult fracture pattern.

Funding : Other Education Grant

Funding Parties : Capital Health Research Grant